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Diseases of the Heart: 

Their Diagnosis and 
Treatment. 



By ALBERT ABRAMS, A. M., M. D., 
(Heidelberg), F. R. M. S., 

rONSULTING PHYSICIAN FOR DISEASES OF THE CHEST, 

MT. ZION HOSPITAL AND THE FRENCH HOSPITAL, 

SAN FRANCISCO. 



CHICAGO : 

G. P. ENGELHARD & COMPANY, 
1900. 






THF LiBRAftY OP 
CONGRESS, 

Two COPHi^ RE06IVCD 

CLAS«(X OOCa No. 

corr b. 



Copyright 1900 
By G. P. ENGELHARD & COMPANY. 



CONTENTS. 



Chapter. Page. 

I. Introduction to Diseases of the Heart . 11 

II. The Diagnosis of Diseases of the 

Heart 30 

III. General Treatment of Diseases of the 

Heart'. 65 

IV. Affections of the Pericardium 92 

V. Endocarditis and Chronic Valvular 

Disease 109 

VI. Neuroses of the Heart 128 

VII. Affections of the Arteries ; . . . 144 

VIII. Addendum 155 



PREFACE. 

This little book was never intended to aspire 
to the dignity of a treatise on diseases of the heart. 
The primary object was to make it useful to the 
practical physician in the diagnosis of cardiac 
diseases. The cardiac diagnostician is often like 
the veterinarian, for his diagnosis is based essen- 
tially on objective signs. He must depend largely 
on the Baconian or inductive method of ratiocina- 
tion, in contradistinction to the deductive method. 

The former analytic method of diagnosis is a 
conclusion drawn from concrete facts. Mistakes in 
diagnosis may be attributed to the following 
causes: 1. Incomplete or careless examination. 
2. Misinterpretation of symptoms, due to errors 
in judgment. 3. Ignorance of the methods of 
examination. 4. Prejudiced preconception. 5. 
Incompleteness of medical diagnosis. 6. Placing 
too much reliance on the results of treatment. 
7. Incomplete history of the case, and the incom- 
plete development of symptoms. 8. Simulation 
or dissimulation on the part of the patient. 

1. Errors in diagnosis are not so much due to 
ignorance as carelessness. Sir William Savory 
tritely remarks, "Consciousness of one's ignorance 
may do much to avert the errors of carelessness, 
and he who has confidence in his own judgment 
should of all men be most careful in inquiry." 



Unfortunately, we of to-day treat the disease, but 
not the patient. "And I said of medicine, that this 
is an art which considers the constitution of the 
patient, and has principles of reason and action 
in each case." It is but a few years ago, that a 
physician punctured a pregnant uterus with a tro- 
car, believing that he was dealing with a case of 
ascites. We recall the grave error occurring in the 
practice of a famous English surgeon who mistook 
a swelling in the neck for an abscess, who, with 
more precipitation than reflection, plunged his 
lance into the tumor and death from hemorrhage 
resulted. 

2. Under the caption of misinterpretation of 
symptoms due to errors in judgment, mistakes may 
arise from (a) placing too much reliance on the 
subjective symptomatology; (b) giving undue 
prominence to one symptom to the exclusion of 
others; (c) grouping symptoms which are the 
effect of disease, and not the disease itself. When 
the pathologist makes an autopsy he records many 
of the pathological conditions found, as anatomic 
diagnoses. The clinician should be similarly 
guided. It would appear at times as if, in our 
struggle to establish a diagnosis, it would be better 
to make none at all, rather than group symptoms 
under such equivocal expressions as pseudoangina, 
arrythmia, cardiac palpitation, etc. Such expres- 



sions mean practically nothing in etiologic diag- 
nosis. 

3. Ignorance of the methods of examination is 
responsible for many unfortunate mistakes. The 
rejected applicants of insurance companies furnish 
a large contingent. Nephritis is diagnosed because 
albumin is present in the urine, diabetes, because 
sugar is found, and heart disease because murmurs 
are heard. An unprincipled physician could reap 
a harvest, by putting in condition for re-examina- 
tion many rejected applicants, diseased or other- 
wise, for life insurance. 

4. Prejudiced preconception arises from two 
causes: (a) Placing too much reliance on the 
history of the patient; (b) being misled by first 
appearances. Like the critic who never read a 
book before he received it because he might be 
prejudiced, so it should be with the physician — 
he should not learn the history of his patient be- 
fore he examines him. Diseases present such vari- 
ous pictures, that with our mental astigmatism, 
we can see anything we want. The personal his- 
tory of the patient should only be used in confirm- 
ing the objective examination. 

5. When a disease runs a typic course diagnosis 
is, as a rule, easy ; but when the affection is a typic, 
one is frequently led into error. The physician 
is too often inclined to misinterpret the limitations 
of his art, mistaking the latter for his own delii^ 



quencies. Myocarditis is more often an anatomic 
than a clinic diagnosis. Differentiation between 
cardiac dilatation and pericardial effusion is ex- 
ceedingly difficult at times and to puncture the 
dilated heart with the idea that the latter condition 
is present is a gross error. Treatment should never 
be attempted before a diagnosis »is made. Better 
no treatment than meddlesome therapy. Qui 
bene dignoseit, bene curat. It is related of 
Frerichs, that after examining a patient, he was in 
doubt about the diagnosis. The patient insisting 
about knowing the nature of his trouble, Frerichs 
comforted him with the assurance that the diag- 
nosis would be determined at the autopsy. 

6. We are frequently led into error by mistak- 
ing recovery for cure, thereby ignoring the vis 
medicatriz naturae. I have seen many patients 
with organic cardiac murmurs, the latter becom- 
ing less intense after the administration of chalyb- 
eates. Under the circumstances, one would be 
inclined to regard the murmurs as anemic. Upon 
more mature consideration, this view would be 
dispelled. Impoverishment of the blood attends 
nearly all organic cardiac affections and only suc- 
ceeds in intensifying the murmurs, hence iron only 
removes the factor in intensification. 

7. Diagnosis must be held in abeyance in many 
cases owing to undeveloped symptoms and incom- 
plete history of the case. Problematic diagnoses 



are elusive, and a diagnosis altered to correspond 
with each stage of the patient's illness is no diag- 
nosis at all. 

8. Disease is expressed in a manner peculiarly 
its own. The interpretation of the signs consti- 
tutes diagnosis. The translation may be correct, 
partially correct, or wrong. In all three instances 
the result, as far as the patient is concerned, will, 
as a rule, be the same, provided no treatment is 
instituted. To treat a disease, other than by ex- 
pectant methods, where the diagnosis is wrong, is 
adding insult to injury. 
S. W. cor. Van Ness Avenue and California St. 

December, 1900. San Francisco. 



CHAPTER I. 

INTRODUCTION. 

The heart with its valvular apparatus acts like 
a pump with a suction and pressure valve. Dur- 
ing diastole, it sucks the blood from the veins, and 
during systole drives it into the arteries. There- 
fore during diastole the pressure in the veins 
sinks and rises in the arterial system during di- 
astole. This difference in pressure causes the blood 
to circulate. 

COMPENSATION. 

All heart affections, whether of the valves, 
muscle or pericardium, result in circulatory dis- 
turbances and are characterized by diminished 
pressure in the arteries and increased pres* 
sure in the veins, with retardation of the blood 
current in the capillaries. When the heart by in- 
crease of power and volume opposes the local and 
general disturbances, the lesion is said to be com- 
pensated, and a well compensated valvular lesion 
may be unattended by subjective symptoms. 

Compensation fails when the heart muscle 
(myocardium), in consequence of nutritive dis- 
turbances, degenerates. A valvular heart trouble, 
especially in children, retards development and 



12 



DISEASES OF THE HEART. 



nutrition, leading to cardiac cachexia. The not- 
able tissue changes are thickening of the nose and 
lips and clubbing of the finger ends. 

Overloading of the veins leads to the accumu- 
lation of fluid in the tissues ; beginning first in the 
feet, it gradually invades the rest of the body. 
Fluid also accumulates in the serous cavities 
(pleura, pericardium, brain ventricles). As a 
rule, the peritoneum is the first serous cavity in- 
vaded (ascites). The chief cause of cardiac 
dropsy is disease of the mitral valve, and especially 
mitral stenosis. 

Cyanosis of the skin is an early sign and ap- 
pears as soon as the pulmonic circulation is dis- 
turbed, therefore cyanosis is more evident in mitral 
than in aortic lesions. The cutaneous veins are 
filled with blood and may become varicosed. 
Jaundice, due to catarrh of the bile passages, is not 
uncommon. Cutaneous hemorrhages from rup- 
ture of the capillaries or caused by emboli may 
develop. 

The temperature of the body may be normal or 
lowered, owing to the retarded circulation. Inter- 
current elevations of temperature may be caused 
by emboli in the viscera or lung infarcts. 

PULSE. 

The pulse has a specific character in nearly every 
valvular lesion. Disturbance of compensation gives 
a frequent, irregular, soft and feeble pulse. An 



INTRODUCTION. 13 

intermittent pulse is caused by feeble heart con- 
tractions which are not strong enough to drive 
the blood to the radial artery. In such instances, 
if the heart is auscultated synchronously with pal- 
pation of the pulse, there are more heart tones 
than pulse beats. 

Palpitation of the heart, a frequent symptom, 
may be subjective, objective, or both. Pain in the 
precordia radiating to the left arm, neck or um- 
bilicus, gives rise to symptoms not unlike angina 
pectoris. This precordial pain is especially fre- 
quent in aortic incompetency and has been at- 
tributed to irritation of the cardiac plexus by the 
dilated aorta. 

BLOOD-VESSELS. 

Emboli and thromboses occur. Emboli from 
the right ventricle pass into the pulmonary arteries 
and cause hemorrhagic infarctions. Emboli origi- 
nating from the left ventricle go to the extremi- 
ties, skin, retina or the viscera. Embolism of the 
spleen is manifested by a sudden chill, fever, per- 
spiration, pain in the splenic region and enlarge- 
ment of that viscus. 

To the foregoing symptoms, hematuria is added 
when the embolus attains the kidney. An embolus 
of the brain reaches that organ usually through 
the left carotid artery. 

LUNGS. 

Dyspnea, especially on exertion, is frequent. 
The dyspnea of heart disease is out of all propor- 



DISEASES OF THE HEART. 



tion to the physical changes in the lungs. Diffi- 
cult breathing is usually caused by pressure of the 
enlarged heart on the lungs, disturbed pulmonic 
circulation, hydrothorax, ascites or bronchial 
catarrh. 

Hemoptysis occurs frequently in mitral disease. 
Hemorrhage may be due to congestion, rupture of 
vessels or hemorrhagic infarcts. Hemoptysis is 
most frequently the result of infarcts, and the 
latter are frequent in aortic disease. Lung in- 
farcts lead to a brownish red sputum not unlike 
that of pneumonia. Stress has been laid on the 
fact that in hemoptysis of cardiac origin, the blood 
is clotty and blackish blue in color. 

Edema of the lungs is a frequent cause of death. 
It gives rise to diffuse crepitant rales and serous 
expectoration. Valvular heart troubles predispose 
to inflammatory lung affections. Glottis edema 
may complicate heart lesions. Epistaxis is not 
infrequent. 

GASTEECTATIC DYSPNEA. 

A frequent cause of dyspnea in heart disease is 
acute dilatation of the stomach. After meals 
patients complain of difficult breathing and dis- 
tress in the precordia, and death has not unfre- 
quently followed an indigestible meal. I have 
called this condition gastrectatic dyspnea, because 
it is always associated with a dilated stomach. In 
some instances dyspnea is associated with symp- 



INTRODUCTION. 15 

toms of angina pectoris. Many patients make- 
no mention of dyspeptic symptoms. They com- 
plain of pressure or weight in the sternal or pre- 
cordial region, and often add that eructation will 
relieve the pressure. This symptom, as I have 
assured myself after examination of a number of 
cases, is dislocation of the heart upwards by an 
acute or chronically dilated stomach. Some years 
ago I reported a case of gastroptosis and merycis- 
mus, with voluntary dislocation of the stomach 
and kidneys.* This phenomenal case taught me one 
fact in particular, how easily the heart could be 
displaced by dilatation of the stomach. The in- 
dividual in question could, by buccal insufflation 
of the stomach, cause his heart to disappear be- 
hind the lungs, so that percussion of the pre- 
cordial region yielded no dullness on percussion. 
This case directed my attention to a correct 
investigation of all individuals presenting them- 
selves for the treatment of slight dyspeptic symp- 
toms in whom sternal pressure was the chief 
subjective symptom. 

In all such cases the diminished area of cardiac 
dullness bears a distinct relation to the severity of 
the pressure symptoms. The removal of ingesta 
and gases from the stomach restores the heart to 
its normal position and feeble heart tones become 
strong. 

*Medical News, April 13, 1895. 



16 



DISEASES OF THE HEART. 



Not infrequently true asthmatic attacks, asthma 
dyspepticum, v/ere present. . The patient is unable 
to get rid of the gases owing to a spasm of the 




Fig. I — Skiascopic picture of the outline of the heart 
and stomach before swallowing the seidlitz powder. 

sphincters of the stomach; the distended stomach 
pushes the diaphragm upward, dislocating the 
heart, and induces typical attacks of asthma. 



INTRODUCTION. 17 

To quickly detect a dilated stomach encroach- 
ing on the chest organs, the following percussion 
method will be found practical. The circular 
tympanitic stomach-lung region formed by the 
stomach beneath the lower lobe of the left lung 
gradually disappears behind the axillary line if 
the stomach is normal, but if dilated, the tympan- 
itic sound may be traced to the vertebral column. 
Sometimes in dyspeptic asthma relief is quickly 
obtained by introduction of the stomach tube and 
allowing the gases to escape. The following il- 
lustrations describe more fully than words the 
influence of a dilated stomach on the position of 
the heart. They are rough reproductions from the 
fluoroscopic picture with the use of the X-rays. 
In the average examination of the chest by the 
X-rays, the portion of the stomach which is in 
direct contact with the chest wall is obscured by 
the shadow cast by the spleen, but in this patient 
no spleen shadow being present and the contour 
of the stomach being clearly defined, opportunity 
was afforded to test the influence of a stomach 
distended by a seidlitz powder on the position of 
the heart.* Every phase of the stomach distention 
was followed in the fluoroscopic picture. 

*Later a similar case came under my observation. 
See "Note on a Case of Nervous Eructations Studied 
by Skiagrams," Philadelphia Med. Journal, Aug. 12, 
1899. 



18 



DISEASES OF THE HEART. 



CARDIAC ASTHMA. 

Cardiac Asthma closely simulates bronchial 
asthma, but the former is associated with some 
anomaly of the heart or arterial system. If such 




Fig. 2 — Shows the same organs after distention of 
the stomach by gas. 

anomalies exist, asthmatic paroxysms may result, 
whenever the pressure in the capillaries of the 
lungs rises. Such rise in pressure may follow an 



INTRODUCTION. 



19 



increased or diminished blood pressure in the 
aorta. In either instance, the capillaries of the lung 
alveoli become surcharged with blood, which in 
turn make the alveolar walls rigid and incapable of 
distension, thus diminishing the respiratory area. 
The following table may assist in differential diag- 
nosis : 



BRONCHIAL ASTHMA. 

Usually absent. 



CARDIAC ASTHMA. 

Signs of cardiac disease 
(valvular lesion, arterio 
sclerosis, fatty heart). 

Dyspnea is equally in- 
spiratory and expira- 
tory. 

Pulse in the early stage 
of paroxysm may be 
strong, but it soon be- 
comes soft and small. 

Percussion shows an ex- 
tension of the borders, 
of the lungs and oblit- 
eration of the area of 
superficial cardiac dull- 
ness. 

Auscultation shows an ab- 
scence of rales unless 
complicated by edema 
of the lungs. 

DIGESTIVE APPARATUS. 

Yenous stagnation conduces to chronic catarrh 
of the gastro-intestinal mucous membrane, re- 
sulting in dyspepsia, constipation, diarrhea and 



Dyspnea is expiratory. 



The pulse is usually one 
of increased tension 
throughout the par- 
oxysm. 

The extension of the lung 
borders is more pro- 
nounced than in cardiac 
asthma. 



Sonorous and sibilant 
rales are always heard, 
louder during expira- 
tion than inspiration. 



20 DISEASES OF THE HEART. 

hemorrhoids. Gastralgia occurring in cardiac 
lesions may mislead the physician if the diagnosis 
is of a stomach trouble. 

LIVER AND SPLEEN. 

The liver participates early in the circulatory 
disturbances. Owing to the venous engorgement 
of the inferior cava, the hepatic veins cannot un- 
load, and the liver in consequence swells and may 
be felt below the border of the ribs as a hard and 
painless mass. Later in the disease, owing to 
atrophy of the liver cells, the organ may become 
reduced in size. Not infrequently the enlarged 
liver may pulsate owing to transmitted pulsations 
from the aorta. It is well to remember that the 
knee-elbow position will usually cause the disap- 
pearance of transmitted pulsations. Stagnation of 
blood in the portal circulation leads to venous en- 
gorgement of the spleen, stomach and intestines, 
with enlargement of the first mentioned viscus. 



From the quantity and constituents of the urine 
the severity of the compensation failure may be 
gauged. The lower the blood pressure in the aorta 
and the higher the blood pressure in the venae 
cavse, the more the urine partakes of the charac- 
teristics of passive congestion of the kidneys. The 
urine is reduced, of high specific gravity, contains 
albumin, casts, and often blood corpuscles. Uric 



INTRODUCTION. 21 

acid is increased and is deposited as a brick dust 
sediment. 

NERVOUS SYSTEM. 

Aortic lesions, particularly owing to brain 
anemia, are often complicated by syncopal attacks. 
Brain hyperemia complicating heart lesions is 
characterized by attacks of fainting, fullness in the 
head, ringing in the ears, etc. Nitrite of amyl 
inhalations are of signal advantage in diagnosis. 
This drug will ameliorate symptoms of brain 
anemia and intensify those of hyperemic origin. 
An embolus in the left arteria fossae sylvii will 
cause hemiplegia on the right side, associated with 
aphasia. Temporary aphasia may occur without 
an embolus and must often be attributed to mere 
circulatory disturbances. Mental diseases are not 
frequent in heart lesions. In some cases a real 
intellectual disturbance exists. Observations are 
recorded of maniacal delirium in patients with 
mitral lesions. Such cerebral troubles may be 
remedied by treatment directed exclusively to the 
heart. 

RELATION OE DISEASES OF THE HEART TO OTHER 
DISEASES. 

An individual with a heart lesion assumes a 
grave risk when attacked by other diseases. This 
is notably the case in febrile affections. In fever, 
the organs show cloudy swelling; a like change 
occurs in the muscles, and the heart manifests the 



DISEASES OF THE HEART. 



granular alteration of its fibres to the highest de- 
gree. These tissue changes arise from contact with 
the poisons circulating in the blood and from the 
accompanying rise of temperature associated with 
disturbances of nutrition. A febrile affection 
therefore may seriously implicate the functions of 
the heart in valvular lesions. 

Intercurrent diseases of the lungs tax the func- 
tions of the right heart to the utmost. 

Pregnancy always causes hypertrophy of the 
heart, but this recedes in the healthy woman after 
delivery. Cardiopathic patients are predisposed 
to acute exacerbations of endocarditis, and a large 
number are always in danger of miscarriage. Du- 
rosier noted that out of forty children born of 
cardiopathic mothers, thirty-seven died before at- 
taining the age of six years. The most unfavor- 
able lesion to the mother from the point of prog- 
nosis is mitral insufficiency, the mildest, aortic 
insufficiency. The most serious complications, and 
the greatest danger of death for the mother, ap- 
pear about the seventh and a half, or the eighth 
month. Cardiopathic mothers should not nurse 
their infants because lactation augments heart 
hypertrophy. 

Endocarditis is regarded by some as the cause 
of chorea; particles of fibrin are supposed to pass 
from the valves as emboli to the cerebral vessels. 
At any rate, endocarditis is very common as a 



INTRODUCTION. 23 

complication, although many of the heart mur- 
murs in chorea may be caused by anemia or the 
rapidly acting heart. 

The belief was at one time current that an in- 
dividual with heart disease was in no danger of 
contracting phthisis. As a rule (pulmonary ste- 
nosis the exception), pulmonary tuberculosis rarely 
develops in an individual with a valvular heart 
lesion. In 277 autopsies on individuals who dur- 
ing life suffered from valvular trouble, Frommalt 
found phthisical lung changes in 8 per cent of the 
cases. These statistics show the infrequency of 
phthisis complicating valvular lesions, since Biggs 
reports that more than 60 per cent of his autopsies 
showed lesions of pulmonary tuberculosis. 

ETIOLOGY OF DISEASES OF THE HEART. 

Endocarditis is the usual cause of valvular heart 
lesions. That part of the endocardium performing 
the most work is the first to become involved and 
suffer most. This explains the rarity of endo- 
carditis on the right side in adults and the infre- 
quencv of congenital lesions on the left side of the 
heart. The process usually implicates the valvular 
endocardium and is therefore known as valvular 
endocarditis. In adult life, about one-half the 
cases of endocarditis occur on the mitral valves; 
of the remaining 50 per cent, about 94 per cent 
occur on the aortic valves ; the remaining cases are 
divided between the valves of the right side, the 



24 DISEASES OF THE HEART. 

tricuspid valve being in the ascendency. It is 
customary to speak of the following forms of endo- 
carditis : 

(a) Acute \ S ™? e ' , 

( malignant. 

(b) Chronic or indurative. 

(a) The acute simple endocarditis is caused by 
acute articular rheumatism in 20 per cent of the 
cases. Among the other causes are : the infectious 
diseases of children, tonsillitis (by many regarded 
as the avenue of rheumatic infection), pneumonia, 
and diseases associated with blood intoxications, 
like diabetes, gout, cancer, and nephritis, especially 
the interstitial form. Various organisms, like 
strepto- and staphylococci, gonococcus, and even 
the bacillus tuberculosis, have been found in and 
on the affected valves, but their casual relationship 
has not been demonstrated. 

The malignant form is of microbic origin and 
is secondary to some infectious disease. The ma- 
jority of cases develop during an attack of croupous 
pneumonia. The other diseases associated with 
the infectious process are: pyemia, septicemia, 
puerperal fever, gonorrhea, erysipelas, puerperal 
fever, diphtheria and rheumatism. 

(b) Chronic endocarditis results from the acute 
forms and from syphilis, alcoholism, gout and ex- 
cessive work for any one valve, 



INTRODUCTION. 25 

RESULTS OF ENDOCARDITIS. 

When restitution of the valve does not take place 
(rare), one of two conditions of clinical import- 
ance occurs, narrowing, obstruction or stenosis, or 
insufficiency or incompetency of the valves. In 
either instance, murmurs are heard resulting from 
obstruction to the onward flow of the blood or from 
leakage backwards through a closed but incompe- 
tent valve. The former are known as obstructive, 
the latter as regurgitant murmurs. 

RESULTS TO THE HEART. 

The inevitable consequence to the heart in a 
valvular lesion is increased work, leading to hyper- 
trophy or dilatation. 

Hypertrophy is muscular thickening of the walls 
of one or more cavities of the heart, and rarely 
occurs without some dilatation of the cavities. 
Increased work of the heart, when nutrition is 
plentiful, is followed by hypertrophy. Overwork, 
beyond the nutrition and muscular power of the 
heart, results in dilatation. Hypertrophy is a 
favorable compensatory condition in cardiac les- 
ions ; it is the response of the cardiac muscle to an 
increased demand for power. It can only develop 
when the health of the organism is maintained at 
the proper standard, and when this fails the com- 
pensation attempted by nature must fail, and then 
hypertrophy passes into dilatation. 

Heart strain is a prolific etiologic factor in dis- 



^O DISEASES OF THE HEART. 

eases of this organ and of the aorta. The initial 
effect of prolonged exertion is dilatation of the 
right side of the heart. The effect of sudden strain 
is on the aortic area. Peacock found, in 17 cases 
of rupture of the heart valves after sudden strain, 
that the aortic valves were implicated ten times, 
mitral valves four times, and the tricuspid valves 
three times. Schott* has demonstrated in a series 
of skiagraphs that dilatation of the heart after 
wrestling can be demonstrated by the Eoentgen 
rays. 

In recent years, heart disease, resulting from 
overstrain after bicycling, has been frequently ob- 
served. I have examined a few individuals with 
the X-rays who have done "century runs," and 
have demonstrated dilatation of the right heart 
following such foolhardy attempts. I have per- 
sonal knowledge of five individuals who have be- 
come heart cripples from excessive bicycling. 

The size of the heart chambers varies in health. 
In severe exertion the chambers dilate, especially 
those of the right side, to accommodate themselves 
to the increased quantity of blood; this compen- 
sation on the part of the heart is "the getting of 
wind," as it is called in training. When an indi- 
vidual in poor condition subjects himself to heart 
strain he suffers from rapid and feeble pulse, car- 
diac dyspnea and precordial pain, and for months 



*Medical Record, March 26, li 



INTRODUCTION. 27 

after he may be unfitted for severe exertion or be- 
came permanently crippled. Systematic and 
judicious muscular exercise develops heart hyper- 
trophy, a propitious condition when great en- 
durance is demanded. Injudicious exercise weak- 
ens the heart. 

Relative valvular insufficiency (i. e., normal 
valves which are no longer capable of completely 
closing the orifices of the heart), especially of the 
tricuspid valves, frequently follows heart strain. 
In men the aortic valves are more frequently impli- 
cated than in women. This is owing, no doubt, 
to the fact that bodily exertion predisposes to 
arterial disease. Among the laboring classes valv- 
ular lesions are most frequent. 

FREQUENCY OF INDIVIDUAL VALVULAR LESIONS. 

In extra-uterine life the most frequent valvular 
lesion is mitral insufficiency, then follows mitral 
stenosis, combined with mitral insufficiency, then 
aortic insufficiency, then aortic stenosis, and finally 
aortic stenosis combined with aortic insufficiency. 
Combined lesions are not infrequent. Mitral and 
aortic lesions may coexist and less often mitral 
and tricuspid lesions. In children, the most com- 
mon combination is aortic and mitral insufficiency. 

PROGNOSIS OF DISEASES OF THE HEART. 

The prognosis in valvular lesions is unfavorable. 
Cure may be spontaneous, but is never attained by 



«8 DISEASES OF THE HEART. 

medication. Aortic are more favorable than other 
lesions, owing to the ability of the voluminous 
left ventricle to compensate the defect. Pulmo- 
nary lesions are especially unfavorable, owing to 
the frequency of phthisis complicating such 
lesions. Combined lesions of different valves are 
more unfavorable than lesions of individual valves, 
owing to the increased work thrown on the heart. 
The social position of the patient influences the 
prognosis. Occupation which demands little mus- 
cular effort and permits a sedentary life favors 
longevity. The stronger the constitution the 
greater the likelihood of the heart being able to 
meet the increased demands made on its power. 
Valvular lesions acquired in childhood soon result 
in compensatory disturbances. 

Mechanical troubles of circulation when the 
heart muscle is inadequate to perform its task 
furnish an unfavorable prognosis and lead to a 
lingering illness, death resulting eventually from 
paralysis of the heart, blocking of one of the 
branches of the coronary arteries, lung edema or 
debility. In other instances death is sudden from 
heart rupture or cerebral complications. So long 
as an efficient compensation is maintained in val- 
vular disease, even the most serious valve lesion is 
unattended by inconvenience to the patient. Sir 
Andrew Clark summarized the following condi- 
tions which justified a favorable prognosis : Good 



INTRODUCTION. 29 

general health; just habits of living; no excep- 
tional liability to rheumatic or catarrhal affec- 
tions; origin of the valvular lesion independently 
of degeneration; existence of the valvular lesion 
without change for over three years; sound 
ventricles, of moderate frequency and general reg- 
ularity of action; sound arteries, with a normal 
amount of blood and tension in the smaller ves- 
sels; free course of blood through the cervical 
veins; and lastly, freedom from pulmonary 
hepatic and renal congestion. 



CHAPTER II. 

THE DIAGNOSIS OF DISEASES OF 
THE HEART. 

SIGNIFICANCE OF MURMURS. 

No fallacy in medicine has been more carefully 
nourished than the belief that a cardiac murmur 
is always indicative of heart disease. Some of 
the most serious heart affections are unaccom- 
panied by murmurs. "The idea that a murmur 
in itself and by itself is a serious thing dies 
hard" (Shattuck). Sir Andrew Clark gave utter- 
ance to the truism "that a murmur in itself is of 
little or no moment in determining the prognosis 
of any given case. Osier voices the opinion of the 
skilled cardiac diagnostician as follows: "Prac- 
titioners who are not adepts in auscultation and 
feel unable to estimate the value of the various 
heart murmurs should remember that the best 
judgment of the conditions may be gathered from 
inspection and palpation. With an apex beat in 
the normal situation and regular in rhythm, the 
auscultatory phenomena may be practically disre- 
garded." THE APEX BEAT. 

We must always remember that disease of the 
heart valves of any consequence to the patient, 



DIAGNOSIS OF DISEASES OF THE HEART. 31 

always leads to functional and structural heart 
changes and unless the latter can be demonstrated, 
the diagnosis of valvular disease should be held 
in abeyance. Fowler is responsible for the epi- 
gram: "That the position of the cardiac apex is 
the key to the diagnosis of nearly all affections of 
the chest and heart." 

The normal location of the apex beat excludes 
dilatation, hypertrophy, pericardial effusion and 
heart dislocation. 

CARDIAC MURMURS. 

Adventitious sounds originating in the peri- 
cardium heart and blood vessels are known as 
murmurs. The auscultation of a murmur sug- 
gests many problems in diagnosis. Having de- 
termined the presence of a murmur the first prob- 
lem to unravel is its origin. The most frequent 
murmurs are endocardial in origin and they are 
divided into organic (if caused by anatomic 
changes of the heart or blood vessels) and inor- 
ganic or functional murmurs (caused by changes 
in the quality of the blood. An organic murmur 
may be obstructive or regurgitant. Two prob- 
lems await solution: First, the seat of the mur- 
mur; second, the nature of the murmur. 

The seat of the murmur is determined by noting 
its position of maximum intensity and the direc- 
tion of its transmission. These facts apprise us 
of the valve orifice affected. 



32 DISEASES OF THE HEART. 

THE ORIFICE AFFECTED. 

The position of maximum intensity of a mur- 
mur usually occurs at the point where the normal 
valve sound is best heard in health. We must not 
forget that the heart orifices are closely situated 
and therefore murmurs are created within a lim- 
ited area; if it were not for the fact that mur- 
murs have directions of selective propagation it 
would be impossible to determine at which valve 
orifice the murmur was generated. 

DIRECTION OF TRANSMISSION", NATURE AND TIME. 

In general, systolic murmurs of aortic origin are 
transmitted upwards from the base. Systolic mur- 
murs of mitral origin are transmitted toward the 
axilla. The transmission of a murmur is in the 
direction of the currents which produce them. 

Our next duty is to determine the nature of the 
murmur, which is ascertained by noting the time 
of the murmur and the direction of its propaga- 
tion. Organic endocardial murmurs may be ob- 
structive when there is obstruction to the onward 
flow of blood, the nature of the lesion being a 
stenosis and regurgitant murmurs when there is 
leakage backwards through a closed but incompe- 
tent valve, the nature of the lesion being an in- 
sufficiency. 

Organic heart murmurs have a definite relation 
to the cardiac cycle and we distinguish systolic, 
diastolic and 'presystolic murmurs. 



DIAGNOSIS OF DISEASES OF THE HEART. 66 

SYSTOLIC MURMURS. 

The systolic murmurs arise from aortic ob- 
struction, and mitral and tricuspid regurgitation. 
Systolic murmurs are synchronous with the caro- 
tid pulse, therefore in a rapidly acting heart, the 
time of the murmur may be determined by pal- 
pation of the carotid pulse during auscultation. 
The radial pulse should not be selected because it 
is felt too long a time after systole. 

The diastolic murmurs are aortic regurgitation, 
and mitral obstruction. The so-called presystolic 
murmur is associated with mitral stenosis : it 
occurs at the end of systole, or, in case it is pres- 
ent at the beginning of diastole, it becomes 
stronger toward the end. 

CHARACTER OF MURMURS. 

Eegurgitant murmurs as a rule are soft and 
blowing. The murmur of aortic regurgitation is 
characterized by length and softness, while the 
murmur of mitral regurgitation is louder, but not 
so long. Murmurs that are rough and high in 
pitch are usually generated by valves which are 
thickened and rigid, a common condition in 
chronic endocarditis. Murmurs soft and low in 
pitch are associated with soft exudations on the 
valves and are heard in endocarditis of rheumatic 
origin. The murmur of mitral obstruction is the 
only murmur which has a specific character. It 



34 DISEASES OF THE HEART. 

is a prolonged murmur of a churning or grinding 
character as if fluid were being forced with great 
effort through a narrow channel. 

Murmurs may sometimes be felt in the heart 
region. The sensation is similar to that perceived 
upon stroking the back of a purring cat ; for this 
reason, they are called purring tremors. Like mur- 
murs, they may be presystolic, systolic, or diastolic 
in time. They are nearly always indicative of a 
valvular lesion. 

SECONDAEY EFFECT OF VALVE LESIONS. 

Having ascertained the endocardial character of 
the murmur and the seat of the lesion our next 
endeavor is to confirm our diagnosis by determin- 
ing the all important fact, viz. : the secondary 
effect of the lesion on the heart. Without this 
corroboration the detection of a murmur is with- 
out diagnostic or prognostic importance. 

Aortic Obstruction. — Owing to the obstruction 
of blood from the left ventricle, the latter must 
work with increased force, therefore it hyper- 
trophies. Less blood on account of the stenosis is 
thrown into the arterial system, hence the pulse 
is small and of high tension owing to the hyper- 
trophied left ventricle. Aortic Regurgitation. — 
The blood flowing back into the left ventricle dur- 
ing diastole, causes this chamber of the heart to 
enlarge (dilatation), but compensation occurring, 
the dilatation is overcome by hypertrophy of the 



DIAGNOSIS OF DISEASES OF THE HEART. 35 

ventricle. The pulse of aortic regurgitation is 
pathognomonic. It is called the Corrigan or "wa- 
ter hammer pulse." The impression received by 
the finger on the radial artery is one of recedence 




Fig. 3 — Auscultatory areas of the valves and points 
of maximum intensity of the murmurs: M, mitral 
valve; T, tricuspid; P, pulmonary; A, aortic. Ana- 
tomic position of the cardiac valves: t, tricuspid; m, 
mitral; a, aortic; p, pulmonary. 

of the pulse wave as soon as it strikes the finger. 
The phenomenon is accentuated if the arm is 
raised. 



36 DISEASES OF THE HEART. 

Mitral Regurgitation. — In this lesion the brunt 
of the work is thrown on the right ventricle, which 
dilates and hypertrophies. The increased tension 
of the pulmonary artery is evidenced by accentu- 
ation of the second pulmonic tone. The arterial 
system receives less blood leading to insufficient 
nourishment of the heart through the coronary 
arteries, hence degeneration of the organ must 
ensue. 

In Mitral Obstruction it is the left auricle 
which primarily hypertrophies to overcome the 
narrowed mitral orifice. Later, the right ventricle 
hypertrophies. 

ACCIDENTAL HEART MUEMURS. 

There are a number of accidental heart mur- 
murs, functional in their nature, which admit 
of no definite classification. As a rule, they are 
unattended by any palpable changes in the heart 
or pulse. They are almost invariably systolic in 
time. In my experience, they are frequent before 
operations and in gastric disturbances. There are 
many individuals, chiefly women in whom func- 
tional murmurs appear just before an expected 
operation and disappear with equal readiness a 
few days after the operation. They might correct- 
ly be called "murmurs of apprehension." 

The other class of murmurs associated with 
stomach disturbances, which for purposes of con- 



DIAGNOSIS OF DISEASES OF THE HEART. 37 

venience I will designate as "murmurs of gastric 
origin," I have encountered frequently. They 
usually coexist with digestive disturbances and are 
sometimes of great intensity. Such individuals 
complain of precardial pain and pressure and the 
disappearance of the latter symptoms mark the 
evanescence of the heart murmurs. The mur- 
murs are in no wise associated with the pressure 
of a dilated stomach on the heart as would be 
primarily surmised, for I have never been able in 
such individuals after disappearance of the mur- 
murs to recreate them by artificial insufflation of 
the stomach. Other causes must exist and the most 
likely cause is reflex irritation of the cardiac nerves 
superinduced by the toxic products of gastric in- 
digestion. While stress has been laid on the fact 
that functional murmurs are in the great majority 
of instances systolic in time, we must not forget 
that they may also be diastolic. In my experience 
I have encountered such murmurs in anemia, 
with their maximum intensity over the auscultatory 
situation of the aortic orifice and they may be 
traced to the jugular veins in the neck, their un- 
doubted point of origin. Care must be exercised in 
distinguishing such murmurs from those oc- 
curring in aortic incompetency, an error which is 
hardly possible, if all the facts in this chapter 
are carefully considered. The foregoing facts 
prompt us to hold in reserve the diagnosis, "or- 



OO DISEASES OF THE HEART. 

ganic heart murmur," without repeated examina- 
tions of the heart, for it is evident that, if at one 
examination, we note, let us say, a systolic murmur 
at the mitral area and at a subsequent examination 
a systolic tone, as a rule there can exist no organic 
disease of the valve. 

ANALECTIC REVIEW OF CARDIAC VALVULAR MUR- 
MURS. 

1. The character or intensity of a murmur is 
no index to the gravity of the lesion producing it. 
The loudest murmur may be produced by the 
smallest lesion and vice versa. 

2. The loudness of a murmur is largely de- 
pendent on the activity of the heart. Loud mur- 
murs may become weak, and this change is an 
ominous sign indicating heart weakness. For the 
same reason they may disappear in febrile dis- 
eases and in the dying state. Faint may often 
be converted into loud murmurs after increasing 
cardiac activity by exercise and cardio-tonic 
medication. Complete compensation may often 
cause the temporary disappearance of a murmur. 

3. In some individuals murmurs are louder in 
the recumbent than in the erect posture, especially 
murmurs of tricuspid and mitral origin. Mur- 
murs should be auscultated with the patient in 
different postures. 



DIAGNOSIS OF DISEASES OF THE HEART. 39 

4. Murmurs are less loud in inspiration than 
expiration. 

5. Strong pressure on the chest, especially in 
children, may cause the disappearance of mur- 
murs, the pressure inhibiting cardiac action. 

6. When the heart is rapid or irregular in 
action, it is difficult to determine the time of a 
murmur. Remember that systolic murmurs are 
synchronous with the carotid pulse. Also regu- 
late the action of the heart with digitalis. 

7. Systolic are usually louder though less pro- 
longed than diastolic murmurs. 

8. When murmurs are faint, have the patient 
suspend respiration during auscultation. 

9. Murmurs are most intense at their point of 
origin and they are propagated in the direction of 
the blood current by which they are developed. 

10. Murmurs of extra-uterine origin are 
oftener found to proceed from the valves of the 
left heart, and in adults, murmurs at the tri- 
cuspid and pulmonary areas are rare. 

11. In rare cases the murmur may be heard at 
a distance without laying the ear over the chest 
and they may be perceived by the patient. Only 
those arising at the aortic opening have this pe- 
culiarity. 

12. When two murmurs co-exist at systole or 
diastole they may be transmitted or be due to dis- 
ease at different orifices. Thus two murmurs oc- 



40 DISEASES OF THE HEART. 






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DIAGNOSIS OF DISEASES OF THE HEART. 41 

curring at systole may be due to mitral insuf- 
ficiency and aortic stenosis or if occurring 
during diastole, to mitral stenosis and aortic 
insufficiency. Differentiation is possible in two 
ways : First, by the character of the murmur. If 
one is blowing and the other rough, two distinct 
murmurs exist. If both are similar in character, 
then there is only one, which is transmitted from 
its point of origin at one opening to the second 
opening. 

Second: Auscultate from the point where one 
murmur is heard to where the other exists, as 
from the apex to the aorta. If the murmur is 
everywhere distinct but it becomes gradually 
louder toward one point, then it arises at this 
point and is transmitted to other points. If, on 
the contrary it is no longer heard at some point 
between the apex and the aorta, and is again 
audible at the aorta, then there are two murmurs. 

13. Never diagnose a valvular lesion without 
taking into consideration the effects of such a 
lesion on the heart and blood vessels and demon- 
strating them. 

PERICARDIAL MURMURS. 

These are friction sounds produced by the rub- 
bing of one surface of the pericardium upon the 
other when roughened by a fibrinous exudate 
which occurs in the plastic variety of pericarditis. 
The following characteristics will aid in distin- 



42 DISEASES OF THE HEART. 



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DIAGNOSIS OF DISEASES OF THE HEART. 43 

guishing pericardial or exocardial from endocar- 
dial murmurs : 

1. Unlike endocardial murmurs which are 
limited to a certain phase of the heart's action, 
they might be systolic, diastolic, or both, or even 
presystolic. 

2. They are increased in intensity upon pres- 
sure with the stethoscope, which maneuver fa- 
cilitates the friction between the pericardial layers. 

3. During inspiration the lung approximates 
the layers of the pericardium, thus increasing dur- 
ing this phase of respiration, pericardial mur- 
murs. Endocardial murmurs by the same act are 
diminished in intensity, because the interposed 
lung offers a poor medium of conduction to the 
chest wall. 

4. The closer the two layers of the pericardi- 
um are approximated, the louder the murmur. 
To facilitate this approximation I would suggest 
pressure being made in the intercostal spaces and 
not on the ribs, as is the conventional practice. 
The same maneuver is applicable in the elicitation 
of pleural friction sounds. To make pressure 
with the stethoscope in the intercostal space, a 
phonendoscopic attachment may be fitted to the 
chest piece of any stethoscope according to the 
illustration. A piece of tin may be easily fitted by 
anv tinsmith. In the center of the tin a rod termi- 
nating in a small button is screwed, 



44 



DISEASES OF THE HEART. 




Fig. 4 — Dr. Abrams' Modified Stethoscope. 

5. They are circumscribed and are not trans- 
mitted beyond the area of cardiac dulness. 

6. Change of position exerts a greater influence 
on the character of pericardial than endocardial 
murmurs. The former are especially distinct 
when the patient is in the sitting posture, with 
the body inclined to the left side. 

7. They give the impression of being superficial 
in origin. 

8. They frequently change their character, 
whereas the character of endocardial murmurs is 
almost constant. 

9. They are rough, grating to and fro, or rub- 
bing and scratching sounds. 

10. When doubt arises whether a murmur is 
peri or endocardial in origin always remember 
that organic endocardial murmurs modify the 



DIAGNOSIS OF DISEASES OF THE HEART. 45 

pulse and induce secondary effects upon the muscle 
of the heart. 

PLEUEO-PEEICAEDIAL MUEMUES. 

1 These murmurs often simulate pericardial mur- 
murs. They arise when the pleura or peritoneum 
adjacent to the heart is roughened. They are 
modified by respiratory movement, disappearing 
or diminishing when the breathing is suspended or 
disappearing after forced expiration. Deep in- 
spiration will usually accentuate them. 

CAEDIO-EESPIEATOET MUEMUES. 

These are sounds synchronous with the heart's 
action, produced outside this organ and heard usu- 
ally to the left of the apex beat. Two factors enter 
into the production of these murmurs. 1. Forcible 
expulsion of air from the lungs by the heart strik- 
ing against it. 2. With each cardiac contraction 
the bulk of the heart is reduced in size and a cor- 
responding vacuum produced in the chest, which 
the lung compensates by expanding, thus produc- 
ing a murmur. 

AXEMIC MUEMUES. 

In anemia murmurs are frequently heard over 
the heart and vessels. They are endowed with 
certain characteristics : 1. They are soft and 
blowing in character and not prolonged. 2. They 
are systolic in time. 3. Generally loudest at the 
base of the heart and especially over the pulmonary 
orifice, a point where organic systolic murmurs are 



46 DISEASES OF THE HEART. 

often heard. The chief means of differentiation 
between the two lies in the fact that with organic 
we find dilatation and hypertrophy of the heart 
which are usually absent in anemic murmurs. 4. 
They are unaccompanied by changes in the size 
of the heart. 5. They frequently change their 
character. 6. They are accompanied by anemic 
symptoms and murmurs in the veins of the neck. 
7. They are louder in the recumbent than in the 
upright position. 8. They are not transmitted 
away from the heart. 9. Under appropriate treat- 
ment with chalybeates they can be made to dis- 
appear. 

PULMONARY ANEMIA, 

I have described (Medical Standard, Jan. 1900) 
an anemia of pulmonary origin, in which anemic 
murmurs are frequent. In this form of anemia 
the ferruginous preparations are without effect 
on the murmurs which only yield to systematic 
lung development, inasmuch as the cause of pulmo- 
nary anemia is dependent on collapsed areas of 
lung. 

HEMIC MURMURS IN THE LARGER ARTERIES. 

The normal systolic and diastolic heart sounds 
are heard in the carotid and subclavian arteries. 
Pressure with the stethoscope over one of the large 
arteries will create a systolic murmur. Murmurs 
from the heart are often propagated to the large 
arteries. Of all the arterial murmurs likely to 



DIAGNOSIS OF DISEASES OF THE HEART. 47 

perplex the physician, the subclavian murmur is 
the most frequent. It is regarded by many clin- 
icians as a sign of phthisis. From an investiga- 
tion of more than 300 cases (Vide my paper 
Medical Standard, Oct., 1899), I am able to 
formulate the following conclusions : 

SUBCLAVIAN MURMUR. 

1. The subclavian arterial murmur is an inde- 
pendent and rarely a transmitted murmur. 

2. Its point of maximum intensity is the fossa 
of Mohrenheim, with feeble tendency to propa- 
gation. (The fossa is a depression under the 
clavicle in the outer part of the infraclavicular 
region between the pectoralis major and deltoid 
muscles. ) 

3. It is heard most often on the left side, less 
frequently on both sides and least frequently on 
the right side. In order of frequency it is heard at 
the height of inspiration, at the end of expiration 
and after momentary suspension of respiration. 

4. It is usually a succession of. murmurs uni- 
form in character and intensified by certain 
maneuvers, notably deep inspiration, suspension 
of respiration and voluntary stretching of the 
neck. 

5. One of its chief characteristics is its mo- 
mentary duration, disappearing usually after a 
few deep inspirations. 



48 



DISEASES OF THE HEART. 



6. Its dependence on the phases of respiration 
distinguishes it from all transmitted murmurs. 

7. It may be present at one and absent at a 
subsequent examination, and neither its character 
nor duration is ever uniform from one examina- 
tion to another. 

8. The position of the patient may influence its 
genesis, but this is never sufficiently uniform to be 
of practical value. 

9. A phthisical lung is not specially propitious 
to its occurrence, as it is found nearly as often in 
healthy as in phthisical persons. 

10. It was present in thirty-six per cent of all 
healthy persons examined, advantage being taken 
in this enumeration or re-examination and those 
propitious factors which determine its occurrence, 
viz. : respiration and decubitus. 

11. The venous subclavian murmur was only 
heard in six individuals with a preponderance of 
its occurrence on the right side. 

12. The arterial subclavian murmur could be 
artificially induced on the left side in nearly 80 
per cent of all individuals examined, and on the 
right side in about 65 per cent of the cases by a 
simple maneuver, viz., raising the arm gradually 
until it assumes a vertical position, while auscul- 
tating the Mohrenheim fossa during the time that 
the arm is brought to the latter position, the mur- 



DIAGNOSIS OF DISEASES OF THE HEART. 49 

mur suddenly appearing at some time during the 
execution of the movement. 

13. By the foregoing maneuver the subclavian 
venous murmur could be induced on the right 
side in 43 per cent of all persons examined. 

DIAGNOSIS OF ENLARGEMENT OF THE HEART. 

Thickening of the muscular walls of the heart 
is known as hypertrophy, while enlargement of 
one or more chambers of the organ is known as 
dilatation. 

HYPERTROPHY OF THE HEART. 

In hypertrophy, the left ventricle is most fre- 
quently involved owing, to the increased work put 
on it by valvular lesions, diseases of the blood 
vessels, muscular exertion, etc. Its fellow ventricle 
on the right side hypertrophies in valvular lesions 
and in lung diseases whenever there is obstruction 
to the blood flow through the pulmonary organs, 
or, as we often say, increased resistance in the 
pulmonary circulation. 

The symptoms of hypertrophy of the left ven- 
tricle are those of increased tension in the arterial 
system, viz. : congestive headaches, noises in the 
ears, and flushing of the face. The physical signs 
of the increased tension are: forcible and heavy 
heart impulse, the first sound at the apex is dull 
and prolonged while the second aortic tone is 
accentuated. The sounds are of course modified 
if valvular lesions are present. The pulse is reg- 



50 DISEASES OF THE HEART. 

ular, full, strong and of high tension. In hyper- 
trophy of the right ventricle, increased tension 
may be manifested by hemoptysis owing to rup- 
ture of the blood vessels. Eeliance, however, must 
be made on the objective examination. Over the 
tricuspid area, the first tone is louder and more 
prolonged than normal, while the second pulmonic 
tone is accentuated. 

Hypertrophy is usually attended by dilatation, 
hence in left ventricle hypertrophy, the apex beat 
instead of being felt in the fifth interspace, two 
inches below and one inch to the right of the left 
nipple, is felt in the sixth, seventh or eight inter- 
space, from one to three inches outside the nipple. 
Percussion shows increased dulness upward and 
transversely. If dilatation attends an hyper- 
trophied right ventricle we find, bulging of the 
lower part of sternum, dislocation of the apex 
beat to the left, but rarely displaced downward. 
A marked epigastric impulse is noted in the angle 
between the ensiform cartilage and the seventh 
rib. The percussional area of dulness is increased 
transversely toward the right. 

DILATATION" OF THE HEART. 

Dilatation of the heart is an evidence of weak- 
ness of the organ and it usually follows hyper- 
trophy. It is the very earliest evidence of com- 
pensation failure. The symptoms are the reverse 
of hypertrophy, because the ventricles are ineap- 



Diagnosis of diseases of the heart. 51 

able of emptying themselves at each systole. The 
apex beat is of course dislocated when the left side 
is involved, but it is very feeble and not punctu- 
ated, as in hypertrophy, but diffused. When the 
right ventricle is dilated, the impulse is seen 
and felt to the right of the ensiform cartilage. 
The action of the heart is irregular and inter- 
mittent. The heart tones are feeble and assume 
a fetal heart rhythm (embryocardia), i. e., the first 
and second heart sounds are alike and the long 
pause is shortened. 

THE PULSE IN HEART DISEASE. 

In palpating the pulse we must take into con- 
sideration: 1. Condition of the arterial wall. 2. 
Tension or blood pressure. 3. Volume. 4. 
Ehythm. 5. Frequency. 

CONDITION OF ARTERIAL WALL. 

1. In health the radial artery can easily be com- 
pressed and distinguished from other tissues. In 
atheroma of the arterial system, it is with diffi- 
culty compressed and may be rolled like a cord 
or pipe stem. Atheroma or arterio-sclerosis is a 
senile phenomenon and illustrates the fact, that 
the duration of life is decided by the condition 
of the arteries or, axiomatically expressed, "A man 
is only as old as his arteries." Alcohol, lead, gout, 
syphilis and other intoxications are common 
causes. Atheroma by increasing the blood pres- 
sure results in hypertrophy of the left ventricle 



DISEASES OF THE HEART. 



and the latter sign associated with a high tension 




Fig. 5- 
Diagram to illustrate the effect of dilatation of the 
right and left sides of heart respectively (Gee after v. 
Dusch). Continuous heavy outline, normal heart; dot- 
ted line, dilatation of right side; thin double line, dila- 
tion of left side. 



DIAGNOSIS OF DISEASES OF THE HEART. 53 

pulse and accentuation of the second aortic sound 
are pathognomic of arteriosclerosis. Angina 
pectoris owing to atheromatous involvement of the 
coronary arteries is common in arterio-sclerosis. 

TENSION" OF THE PULSE. 

2. The pressure with which the blood flows in the 
arteries depends upon the degree of peripheral 
resistance and the force of the ventricular contrac- 
tion. Normally, the pulse almost subsides between 
the beats, but little pressure being required to ob- 
literate it. When the tension is increased, the 
artery remains continuously full between the beats. 
A pulse of low tension is soft and very compress- 
ible. It is indicative of heart weakness. 

VOLUME OF THE PULSE. 

3. This is dependent on the amount of blood 
in the artery; therefore in aortic and mitral 
stenosis the volume is small. 

PULSE RHYTHM. 

4. Disturbance of rhythm is manifested by inter- 
mission or irregularity of the pulse beats. Inter- 
mission means a dropping of a pulse beat and may 
occur at regular or irregular intervals. An inter- 
mittent pulse is characteristic of a fatty heart, if 
associated with a weakened first heart sound and 
evidence of failing circulation (edema of the feet). 
It is a symptom of coffee, tobacco, tea or digitalis 
intoxication. An irregular pulse is evidenced by 



54 DISEASES OF THE HEART. 

differences in time, force or volume of successive 
pulse beats and is of more, serious import than an 
intermittent pulse. It occurs in mitral lesions and 
cardiac degeneration. 

FREQUENCY OF THE PULSE. 

5. In nearly all valvular heart lesions, except- 
ing aortic obstruction with failing compensation, 
the pulse may be increased in frequency. Vagus 
disease and heart weakness are associated with an 
increased pulse rate. Diminished frequency of the 
pulse rate (bradycardia) may be associated with 
certain forms of cardiac disease, especially aortic 
obstruction. Appearing late in valvular lesions, it 
is usually an ominous sign. 

The sphygmo graph is an instrument of refine- 
ment to the practical physician in as much as pal- 
pation alone will detect all the variations in the 
pulse. 

RECAPITULATION. 

Mitral Insufficiency. — Pulse is small and feeble 
because the arterial system is devoid of blood. 

Mitral Stenosis.* — Pulse small and irregular 
with increased frequency. 

Aortic Insufficiency. — Rapid recedenee of the 
pulse as it strikes the finger (Corrigan's Pulse), 
especially if arm is elevated. 

Aortic Stenosis. — On account of obstruction to 
the flow of blood, the left ventricle is hypertro- 



DIAGNOSIS OF DISEASES OF THE HEART. 55 

phied, hence the pulse is one of high tension but 
lessened in volume. 

Myocarditis. — Pulse small, soft and irregular; 
frequency, normal, diminished or increased. 

A comparatively strong pulse, with feeble apex 
beat and heart tones is of great value in the diag- 
nosis of exudative pericarditis. The strength of 
the right ventricle should never be gauged by the 
pulse, the loudness of the second pulmonic tone 
should be the index of its vigor. 

Measuring the Intensity op the Heart 
Tones. 

We are unfortunately in possession of no accu- 
rate means of registering the heart tones to facili- 
tate accuracy in determining the progress of 
patients with heart lesions, or the action of cardio- 
tonics. I have already reported (Medical News, 
July 8, 1899) the following method, which is only 
relatively accurate: 

It is based on the simple physical principle that 
the intensity of sound varies inversely as the 
square of the distance from the sounding body, 
hence the distance to which a heart sound may be 
heard depends upon its intensity, ignoring of 
course those adventitious causes of propitious con- 
ductivity. Between the area auscultated and the 
stethoscope a medium is interposed. Experiment 
has taught me that one of the best media is par- 
tially vulcanized rubber in the form of a rod, and 



56 DISEASES OF THE HEART. 

just sufficiently soft as not to interfere with con- 
venient manipulation. Such rods may be pur- 
chased in any store where rubber goods are sold. 
The circumference of the rods must equal the cali- 
ber of the pectoral end of the stethoscope in which 
they are to be inserted. The degree of insertion 
must be regulated by a notch cut into the rubber. 
The object of this regulation is to insure uni- 
formity of results in the examination of individual 
patients. The rods may be of different sizes, vary- 
ing in length from 6 to 26 centimeters, or even of 
greater length. 

Before auscultating the heart tones by this 
method, we must first mark on the chest the dif- 
ferent points in the precordial region, where the 




Fig. 6. 
Rod inserted into the pectoral extremity of the 
stethoscope for measuring the intensity of the heart 
tones. 

heart tones are heard with the maximum degree of 
intensity. Over each ostium we auscultate with 
the rod inserted into the end of the stethoscope, 
beginning with a rod of medium length and grad- 
ually increasing the length of the rod until one is 



DIAGNOSIS OF DISEASES OF THE HEART. 57 

attained through which the heart tones are no 
longer conducted. The tubes are numbered, and a 
record may be made in our case book after the fol- 
lowing formula. 

Mitral, I tone 6 

Mitral, II tone 5 

Aortic, I tone 4 

Aortic, II tone 5 

Tricuspid, I tone 6 

Tricuspid, II tone 4 

Pulmonary, I tone 4 

Pulmonary, II tone 5 

According to the foregoing formula we conclude 
the following: That with a rod (No. 6) which 
is 26 centimeters in length we may still be able to 
hear the following tones : Mitral systolic and tri- 
cuspid systolic tones. A similar interpretation 
may be deduced from the other numbers. These 
figures possess no value for general application as 
the degree of transmission is dependent on the 
character of the stethoscope as well as the length 
of the rod employed. Each observer must cut his 
own rods of different lengths. With some kinds of 
stethoscopes the first mitral and tricuspid tones 
are still heard with rods fully 30 centimeters in 
length, whereas with other kinds a rod of half the 
length will no longer transmit the same tones. 

In some instances another method may be 
adopted. It is less reliable than the former 
method, especially in thin persons, owing to the 



08 DISEASES OF THE HEART. 

increased conductivity, of the thoracic tissues. As 
before, one marks on the chest wall the different 
situations where the heart tones, corresponding to 
each ostium, are heard loudest, and then proceeds 
in different directions until the sounds are no 
longer audible. The distance to which the sounds 
are propagated is marked and measured. The 
directions in which the sounds are auscultated 
have been determined empirically as follows : 

Miteal Tones. — Auscultate along a line on a 
level with the apex-beat to the left axillary region. 

Teicuspid Tones. — Auscultate along a line ex- 
tending from the point of auscultation to the right 
axillary region. 

Aoktic Tones. — Along a line on a level with 
the point of auscultation to the right axillary 
region. 

Pulmonic Tones. — From the point of auscul- 
tation to the left axillary region. The tricuspid 
and mitral tones are best conducted downward by 
the liver, but as a differentiation of the mitral 
and tricuspid tones over the hepatic region is im- 
possible this direction cannot be employed. I will 
mention, parenthetically, that the liver is an ex- 
cellent conductor of the heart tones, and when 
they are no longer audible by auscultation we can 
safely conclude that the lower border of the liver 
has been reached. 



DIAGNOSIS OF DISEASES OF THE HEART. 59 

Inhibition of the Heart as an Aid in Diag- 
nosis. 

The inhibitory nerve of the heart is the vagus, 
stimulation of which stops the heart in diastole. 
Czermak was able to press his vagus nerve against 
a little bony tumor in the neck, and by thus sub- 
jecting the nerve to mechanical stimulation was 
able to slow or even stop the beating of his own 
heart. If, in almost any healthy person, the caro- 
tid artery, or a point immediately adjacent to it 
in the neck, is compressed, slowing or complete 
inhibition of the heart and pulse ensues. This 
phenomenon is explained by compression of the 
vagus lying alongside the carotid artery. 

Friedreich, and subsequently Sewell of Denver, 
observed that strong pressure with the stethoscope 
on the chest could cause the disappearance of 
murmurs, especially in individuals with an elastic 
thorax, which was attributed to inhibition of the 
heart movements. 

I have endeavored to employ the phenomenon 
of cardiac inhibition as an aid in diagnosis. Ob- 
servation has taught me that, for clinical purposes, 
inhibition of the heart is best attained by forcible 
voluntary contraction of the muscles of the neck. 
In some instances, the inhibitory effect on the 
heart is best observed when the head is stretched 
backward, and, when in this position, contraction 
of the neck muscles is attempted. With some per- 



60 DISEASES OF THE HEART. 

sons, to whom no instructions are intelligible, I 
place a long narrow cushion on the front of the 
neck and then ask them to press with all their 
might on the cushion with their chin. If too 
much violence is used in any of these maneuvers, 
the primary effect will be to increase the rapidity 
of the heart. 

If the maneuver is properly executed, we dimin- 
ish the intensity of cardiac tones and murmurs, 
and it is this fact that determines the real value 
of cardiac inhibition in diagnosis. A few seconds 

Fig. i — Normal pulse. 



Fig. 2 — Pulse during cardiac .inhibition, 
usually elapse before the effect on the heart be- 
comes manifest, then, while the subject is still 
forcibly contracting the muscles of the neck, the 
heart tones become less and less evident, assuming 
an embryocardial character, until finally they are 
no longer audible. The accompanying sphygmo- 
gram was obtained from an individual on whom 
the method was tried for the first time. 

We note almost total annihilation of the pulse 



DIAGNOSIS OF DISEASES OF THE HEART. 61 

after irritation of the vagus by the contracted 
neck muscles. My investigations with this maneu- 
ver may in brief be summarized as follows : 

1. Organic heart murmurs will become faint 
and often inaudible. 

2. Transmitted murmurs are more amenable 
to the maneuver. 

3. The fainter the murmur, the more easily it 
is suppressed. 

4. When a transmitted murmur can be in- 
hibited, the tone which it masks can be auscul- 
tated. 

5. Heart tones are less amenable than mur- 
murs to inhibition. 

6. Hemic murmurs are more readily inhibited 
than organic murmurs. 

7. When the murmurs of anemia are inhibited, 
they are replaced by tones. 

8. Incorrect execution of the maneuver will 
intensify rather than diminish murmurs. 

9. The inhibition maneuver when too often re- 
peated is futile in its results owing to over stimu- 
lation of the vagi. 

10. The maneuver enables us to determine the 
condition of the vagi as inhibitors of the heart 
and guides us in the administration of cardio- 
tonics. 



0« DISEASES OF THE HEART. 

ILLUSTRATIVE CASES. 

The value of the method is illustrated by the 
following cases : 

1. Murmur audible during diastole in the 
second right interspace. At apex, systolic tone 
and diastolic murmur. During inhibition, the 
murmur in the second right interspace becomes 
fainter, while the diastolic murmur at the apex 
disappears and is replaced by a tone. Diagnosis : 
Aortic incompetency. The diastolic murmur at 
the apex is a transmitted murmur. 

2. Loud murmur audible during diastole in 
the second right interspace. At the apex, systolic 
murmur and diastolic tone. During inhibition: 
Murmurs over aorta and apex persist but are less 
loud. Diagnosis: Aortic and mitral incompe- 
tency. The systolic murmur at the apex is not 
transmitted but is dependent on mitral incompe- 
tency. 

3. Systolic murmurs over all the ostia anc? 
not transmitted away from the heart. Blood 
evidence of anemia. Inhibition: Systolic mur- 
murs replaced by systolic tones. Diagnosis : Mur- 
murs of anemia. 

4. Systolic and diastolic murmurs at base of 
heart, modified by pressure with stethoscope and 
position of patient. Anemia not present. Inhi- 
bition : Murmurs disappear and replaced by tones. 
Diagnosis : Pericardial murmurs. 



DIAGNOSIS OF DISEASES OF THE HEART. 63 

5. Murmur at fourth left interspace. Heart 
irregular, and rapid. No anemia nor sign of peri- 
carditis. Inhibition: Murmur disappears to be 
replaced by a tone. Diagnosis : Cardio-muscular 
murmur. 

The X-Eay in Cakdiac Diagnosis. 

A few years ago I exhibited before the Califor- 
nia State Medical Society a series of lantern slides 
illustrating cardiac lesions diagnosed by the aid of 
the Eoentgen rays. Many of my auditors no doubt 
regarded my exhibit as manufactured evidence, 
whereas others, less captious, were inclined to re- 
gard the demonstration as a joke. The vast 
amount of literature that has since accumulated 
has convinced the most skeptical that the Eoentgen 
rays are invaluable in cardiac diagnosis. With 
the rays, we can accurately determine the size of 
the heart and learn in what part the organ is en- 
larged, and all this with more certainty than by 
any other method of examination. Aneurism of 
the heart may be accurately diagnosed, an impos- 
sible feat with other physical methods; aortic 
aneurism may be demonstrated even before sub- 
jective symptoms are experienced. By means of the 
Eoentgen rays, we are enabled to gauge the action 
of digitalis and the Schott method of treatment 
on the heart with perfect ease. Pericardial effu- 
sion, dislocated, transposed and congenital mal- 
formations of the heart may be accurately de- 



64 DISEASES OF THE HEART. 

termined. For all this, two things are essential: 
Good apparatus and the services of an expert in- 
terpreter of skiascopic pictures. "Without a Roent- 
gen ray apparatus no physician can lay claims to 
scientific refinement in cardiac diagnosis. 



CHAPTER III. 

GENERAL TREATMENT OF THE DIS- 
EASES OF THE HEART. 

I. Prevention. II. Treatment during compen- 
sation. III. Treatment during broken 
compensation. IV. Treatment of individ- 
ual symptoms. 

Peevention. 
Acute articular rheumatism is one of the chief 
predisposing factors in the etiology of valvular les- 
ions. We are constrained to heed the wise injunction 
of Sibson, that complete rest, during and after an 
attack of rheumatism lessens the average percent- 
age of cases in which cardiac complications de- 
velop. We may profit by the experience of Cham- 
bers, who tells us, that during an attack of rheu- 
matism, cardiac complications develop less often, 
when patients sleep in blankets and not between 
sheets. Sheets become wet with the acid per- 
spiration and conduce to relapses from chilling of 
the skin. 

The salicylates are almost specific for the 
arthritis, but they are not prophylactic against 
cardiac inflammation. The alkaline treatment ac- 
cording to Garrod, viz. : 40 grains of the bicarbon- 



DO DISEASES OF THE HEART. 

ate of potassium and 5 grains of citric acid, every 
2 hours continuously until the urine becomes and 
remains alkaline and smaller doses thereafter, is 
the most certain means we possess for preventing 
and arresting heart complications. With the 
alkaline treatment the use of salicylates may be 
employed. 

The gouty tendency is often associated with 
high blood tension, arterial degeneration and 
cardiac hypertrophy. Individuals showing this 
tendency must guard against over-feeding, in- 
dulgence in alcohol and live an open air life with 
an abundance of well regulated exercise. The in- 
ordinate use of alcohol is an important factor in 
etiology. Arterial degeneration and heart failure 
associated with dilatation of the organ are well 
recognized conditions in the inebriate. 

Tobacco, like alcohol, must be interdicted in 
those who show a tendency to cardiac dis- 
ease. Tobacco augments the cardiac contractions 
and induces intermittences and irregularities 
(arrythmia) of the heart. In the etiology of 
spurious angina pectoris, nicotine poisoning is 
paramount. An effective argument to induce to- 
bacco habitues to discontinue their habit, is to in- 
struct them to count the pulse before and after 
smoking, when they will invariably note an in- 
crease of from 4 to 11 beats a minute. Coffee and 
tea are not without influence in the etiology of 



GENERAL TREATMENT OF DISEASES OF THE HEART. 67 

affections of the heart, notably, functional dis- 
turbances. 

Syphilis is frequently concerned in endo-peri 
and myocardial lesions. Arterial syphilis is of 
common occurrence. Syphilitics, therefore, must 
be vigorously treated by inunctions or intravenous 
injections upon the advent of cardiac complica- 
tions. Gonorrhea is frequently a factor in the 
etiology of endocarditis, gonococci having been 
frequently demonstrated on the implicated en- 
docardium. 

Moral hygiene is of importance in those predis- 
posed to or suffering from heart disease. All 
emotions directly influence the heart and the 
epigram of Peter is worth repetition, "The physical 
heart is the counterpart of a moral heart." 

Diet is of great moment in many functional 
heart affections. Food must be eaten in small 
quantities and be easy of digestion. Overloading 
the stomach, especially at night, must be avoided. 
Carbo-hydrates, owing to their tendency to form 
gases, must be used sparingly. Laxatives must be 
given to aid the abdominal functions. Digestive 
reflex neuroses of the heart are not infrequent af- 
ter errors in diet. Dyspnea, palpitation and ir- 
regular heart, epigastric pulsation and psychic 
depression are a few of the symptoms following in- 
digestion in some persons. 

The effects of muscular strain on the heart 



68 DISEASES OF THE HEART. 

must not be forgotten, and occupations must be 
recommended which, demand no excessive nor sud- 
den muscular work nor exposure to cold and wet. 
Badly fed laborers often suffer from dilatation of 
the heart without valvular disease. In lifting 
heavy weights, such individuals, first take a deep 
inspiration and then suddenly stop expiration dur- 
ing the time severe exertion is made. The effect 
would be to empty the veins into the chambers of 
the heart leading to dilatation of the cavities. 
Prolonged rest should always follow heart strain, 
otherwise chronic irritability of the heart with 
dilatation ensues. 

Treatment During the Stage of Compensa- 
tion. 

In the early history of medicine, patients with 
cardiac hypertrophy were made the subjects of a 
depleting treatment and they were placed on a 
low diet. Luckily for the patients, this error in 
therapeutics is no longer perpetrated. The prov- 
ince of the physician, during the stage, is strictly 
limited in maintaining the vigor of the heart 
muscle. 

The great majority of those afflicted with com- 
pensated valvular lesions, suffer no inconvenience 
for years nor is the duration of their existence ap- 
preciably abridged. Clark, in 684 chronic val- 
vular lesions which had been kept under observa- 
tion for 5 years, noted no physical inconvenience 



GENERAL TREATMENT OF DISEASES OF THE HEART. 6SJ 

in any of the patients. Unfortunately, the belief 
yet survives, that the demonstration of a cardiac 
murmur, is the signal for digitalis, notwithstand- 
ing compensation is present. Hypertrophy of the 
-heart, which is practically compensation, is an ef- 
fort on the part of nature to overcome the cir- 
culatory disturbances resultant on valvular lesions. 

Our efforts must be directed toward inviting 
hypertrophy and when present to encourage its ex- 
istence. We must "make the heart equal to its 
task" (Beau). To maintain compensation the pre- 
ceding remarks on prevention are germane. 

The rules of prophylaxis can only be executed 
with the intelligent co-operation of the patient, 
who must be informed in a judicious way of the 
nature of his trouble. My almost invariable rule 
is to tell the patient that his trouble is purely a 
functional one, that unless certain laws of health 
are observed, it may become organic. The 
apothegm, "Ignorance is bliss," is especially ap- 
plicable in the case of the cardiopath. "Hope 
springs eternal in the human breast" may refer to 
the phthisical, but never to the cardiac patient. 

Systematic exercise must not be inhibited, on 
the contrary, it is now regarded as an invaluable 
aid in maintaining the muscular power of the 
heart and increasing it. The character of the ex- 
ercise taken is of little moment, provided no 
dyspnea, heart distress or palpitation follows, The 



70 



DISEASES OF THE HEART. 



slightest evidence of such symptoms is a signal of 
danger. 

Provision by the usual preventive measures 
must be taken against catching cold. Every at- 
tack of bronchitis throws an additional burden on 
the heart. Climate is a valuable adjunct in treat- 
ment. Extremes in climate must be avoided. Mild 
temperate climates with cool weather are to be 
favored. High altitudes in general must be 
avoided. Observations teach us that it is the right 
heart which is first overtaxed by a sojourn in high 
altitudes and this observation applies with equal 
cogency to the healthy heart. 
Treatment During Failure of Compensation. 

Broken compensation asserts itself slowly. 
Among the earliest subjective symptoms are 
dyspnea on exertion, nocturnal paroxysms of 
dyspnea and cardiac distress. Objectively, small, 
irregular and feeble pulse and localized edema are 
characteristic. The chief object of treatment is 
to restore the enfeebled heart muscle which is at- 
tained by rest, the use of agents which stimulate 
the heart's action and by methods which relieve 
the embarrassed circulation, viz. : Venesection and 
depletion by purgation. 

The heart receives two sets of nerves, the ex- 
citary from the sympathetic system and the mod- 
erator nerves derived from the pneumogastric. 
While the excitatory nerves put the heart muscle in 



GENERAL TREATMENT OF DISEASES OF THE HEART. 71 

action, the moderator nerves inhibit the move- 
ments, but, by harmonious action of these opposite 
nerve influences, the regularity of the heart con- 
tractions is due. 

Absolute rest in bed is one of the supreme tri- 
umphs of cardiac therapeutics. By this method 
alone, the relief of the symptoms of failing com- 
pensation is oftentimes phenomenal and but two 
or three weeks' rest usually suffice to attain the 
object. The rest must, however, be as absolute 
as in the rest cure method of Weir-Mitchell and 
the nourishment must be equally exacting. If 
anemia is present, the liberal use of some assimil- 
able chalybeate is indicated. In addition, we 
must remember the great value of fresh air, sun- 
shine and a cheerful environment. When rest in 
bed alone fails to restore the circulatory equilib- 
rium, the recourse must be had to cardiac 
stimulants and tonics. 

CARDIAC TOXICS. 

The sovereign heart tonic is digitalis, the 
quinine of the heart. Digitalis slows the action of 
the heart and increases the force of its beats; the 
blood pressure in the arterial system rises with 
contraction of the peripheral arteries. The physi- 
cian is frequently bewildered in encountering in 
the text books, prolix and elaborate indications 
and contraindications for its use. An invariable 
indication for its use is dilatation of the heart, 



72 DISEASES OF THE HEART. 

stationary or progressive, irrespective of the na- 
ture of the valvular lesion. The physician un- 
skilled in methods of cardiac percussion is justified 
in its use, in all cases of compensation failure. 
There are some authorities who declare that its use 
is dangerous in aortic incompetency, because by 
prolonging diastole it promotes the regurgitation 
of blood into the left ventricle. This objection is 
purely theoretic. 

Some contraindications against its use are ex- 
cessive slowing of the pulse present in some cases 
of idiopathic myocardial disease as well as in 
stenosis of the aortic and mitral orifices. The 
danger of arterial rupture, owing to the increased 
blood pressure which attends its physiologic ac- 
tion, I believe to be theoretical. Of one contra- 
indication one can speak absolutely and that is, it 
should never be used when compensation is prop- 
erly balanced. 

When digitalis acts favorably, we note the fol- 
lowing: Pulse becomes slower, regular and in- 
creased in tension. Dyspnea and dropsy disappear. 
The urine formerly scanty, high colored and de- 
positing urates becomes light colored with dimin- 
ished specific gravity and is very much increased 
in quantity. In the use of the drug we must al- 
ways anticipate toxic symptoms which are gradual 
in their appearance, viz.: Nausea, vomiting, small 
irregular pulse and diminished excretion of urine. 



GENERAL TREATMENT OF DISEASES OF THE HEART. 73 

These symptoms usually disappear when the drug 
is withdrawn and are rarely serious. Digitalis 
must be continued until compensation has been re- 
stored. During the course of its administration, it 
is well to suspend its use for a day or so in antici- 
pation of its cumulative action. When nausea at- 
tends its use, it may be given by the rectum, pre- 
ferably in the form of the infusion. 

Digitalis has often been unjustly discredited as 
a drug, owing to many inert preparations found 
in the shops. The most reliable preparations are 
those secured from trustworthy eclectic and 
homeopathic pharmacists as they are in honor 
bound to use the fresh leaves. After curing, 
digitalis leaves rapidly deteriorate. Authorities 
are not in accord on the preparation to be em- 
ployed. Some prefer the watery, others the 
alcoholic preparation. The two preparations are 
by no means identical in action, the glucosides 
(digitalin, digitoxin, etc.) vary in solubility in 
alcohol and water. The watery preparation, the 
infusion, is more effectually diuretic whereas the 
tincture has a more direct influence on the heart. 
The glucosides ought not to be employed, as our 
present knowledge of their composition and phy- 
siologic action is very uncertain. 

The tincture of digitalis is administered in 10 to 
15 minim doses every 3 or 4 hours, the infusion 
in | ounce doses at the same intervals. To secure 



74 DISEASES OF THE HEART. 

the best results with digitalis, I am in the habit 
of giving the tincture before and the infusion 
after meals. Osier voices the opinion of careful 
observers when he expresses the belief that there 
are no substitutes for digitalis. 

Strophanthus. This is the only cardiac tonic 
which possesses any action similar to digitalis, but 
unlike the latter it is less reliable and energetic. 
Strophanthus increases arterial pressure by in- 
creasing the work of the heart, but unlike 
digitalis, it does not contract the blood vessels. It 
may be given continuously without fear of toxic 
manifestations, in fact, its action is only apparent 
after long continued use. In many instances the 
tonic effects on the heart initiated by digitalis may 
be continued with strophanthus which is usually 
given in from 5 to 10 drop doses 3 or 4 times a 
day. 

Caffeine is regarded by some as almost equal to 
that of digitalis in diseases of the heart. It causes 
the beats of the heart to become stronger and oc- 
casionally more rhythmical. Unlike digitalis and 
strophanthus it has no specific action on the in- 
hibitory nerves of the heart. Caffeine is frequent- 
ly of service in cardiac disease when other cardiac 
tonics have failed to give relief and it is of especial 
value in cardiac dropsy alone or combined with 
digitalis. Caffeine is given in doses of from 3 to 
5 grains, 3 or 4 times daily as the natrobenzoate 



GENERAL TREATMENT OF DISEASES OF THE HEART. 75 

or natrosalicylate owing to their increased solu- 
bility and more rapid action. 

Strychnin is a most efficient heart stimulant in 
sudden heart failure. By the mouth, in the doses 
usually recommended, I have seen very little effect. 
It must be given hypodermically in doses varying 
from 1-30 to 1-15 of a grain and frequently re- 
peated. Lately other cardiac tonics have been 
recommended, but they are of subordinate value. 
They may be briefly referred to: 

Spartein. Serviceable in valvular disease when 
dropsy is present. Dose, gr. 1-6 to £ every 4 to 6 
hours. 

Convallaria Majalis (lily of the valley) . Effects 
on the circulation like that of digitalis, but less 
powerful and decidedly more uncertain. The best 
preparation is the infusion, in doses of from 2 
to 8 drachms. 

Adonis. An uncertain cardiac stimulant with 
marked diuretic powers giving it a supposed value 
in dropsy and fatty heart. Dose of the infusion, a 
tablespoonful, 3 or 4 times a day, 

Nitro-glycerine. Cardiac stimulant and arterial 
relaxant. Useful in aortic valvular lesions when 
the object is to give relief to the violently acting 
left ventricle by dilating the peripheral blood ves- 
sels. Dose, one minim three times a day of the 
one per cent solution and increasing the dose one 



76 DISEASES OF THE HEART. 

minim each day until flushing or headache is ex- 
perienced. 

Cocain. Similar in action to strychnin. Dose, 
\ grain every 4 hours. The following tabular re- 
view will recall the essential facts necessary in 
the administration of cardiac tonics. 

THE SCHOTT METHODS BY SALINE BATHS AND 
EESISTED MOVEMENTS. 

These methods produce phenomenal results in 
overcoming the symptoms of disturbed compensa- 
tion even after rest, digitalis and other cardiac 
tonics have failed. By these methods, the results 
achieved are due practically to, (1,) the removal 
of peripheral resistance which increases the 
arterial circulation; (2,) relief of venous conges- 
tion owing to the increased quantity of blood in 
the arteries; (3,) diminished work of the heart 
owing to free circulation of blood in the arterial 
system. 

The Schott treatment is indicated in all func- 
tional disturbances of the heart and in valvular 
lesions complicated by incompensation. It is con- 
traindicated in aneurism, chronic myocarditis and 
marked arterio-sclerosis. For more than 40 years 
the brothers Schott in Nauheim, Germany, have 
been active in the treatment of cardiac diseases by 
gymnastics and baths, but it is only in recent 
years that the Schott treatment has been revived 



GENERAL TREATMENT OF DISEASES OF THE HEART. 77 

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Ii h 11 11 111 



78 DISEASES OF THE HEART. 

in interest. The methods consist in baths and re- 
sisted movements. 

THE BATHS. 

In this country, we are constrained to use arti- 
ficial Nauheim baths. While I do not underesti- 
mate the value of the natural baths at Nauheim, 
I do not consider them absolutely essential. Three 
of my patients, who have taken the baths at Nau- 
heim and the artificial baths at home, claim that 
in effects, there is absolutely no difference between 
the natural and artificial baths. I am inclined to 
believe that the real benefit from the baths is de- 
pendent on the temperature of the water and the 
generation of carbonic acid gas. I pursue the fol- 
lowing method, disregarding the minutiae, which 
are of no practical importance: 

In 40 gallons of water, the amount usually 
necessary for body immersion, the temperature of 
which must be 95° F., 1 pound of sodium bicar- 
bonate is dissolved. After the patient is immersed 
in the bath, 1-| pounds of hydrochloric acid (25%) 
is introduced in a bottle at the lower end of the 
bath tub, which must of course be of porcelain to 
avoid the action of the acid. Gradually the acid 
is poured from the bottle, resulting in the forma- 
tion of carbonic acid gas. The patient remains in 
the bath for 15 minutes on an average, during 
which time he must remain absolutely quiet. 
Baths are given daily for 3 consecutive days and 



GENERAL TREATMENT OF DISEASES OF THE HEART. 79 

then omitted on the fourth day, or about 21 baths 
in one month. The effects observed after the baths 
are almost immediate, viz. : lowering of pulse rate 
and increased strength, relief of cyanosis and dys- 
pnea, marked reduction in cardiac area and a feel- 
ing of exhilaration. 

EESISTED MOVEMENTS. 

These are regular voluntary movements that the 
patient makes which are resisted by the operator. 
The movements are simply flexion, extension, 
adduction, abduction and rotation of the limbs, 
neck and trunk. Each single or combined move- 
ment is followed by an interval of rest. Patients 
must breathe regularly and uninterruptedly during 
the movements. The movements should be gentle 
and must at once be suspended should the patient 
show weariness or any increase in the number of 
respirations or any material increase in the num- 
ber of pulse beats. The same muscles should not 
be exercised twice in succession. The duration of 
each sitting should at the beginning not exceed 
10 minutes, and after the patient has become ac- 
customed to the movements, 30 minutes is usually 
the time limit. 

The baths give more permanent effects than the 
movements, whereas a combination of both meth- 
ods yields the best results. When both are used, 



OU DISEASES OF THE HEART. 

the movements are given in the morning and the 
baths at night.* 

In explanation of the reduction of the size of 
the heart and the good effects observed after the 
Schott treatment, I have espoused the theory (The 
Medical News, Jan. 7, 1899) that the baths and 
movements act by reflex stimulation through the 
skin. What I have called the heart reflex (Phila- 
delphia Med. Journal, Jan., 1900) is a contraction 
of the heart muscle upon application of a cutane- 
ous irritant (vigorous rubbing of the skin or a 
spray of ether to the precardial region). This 
contraction of the myocardium is easily demon- 
strated, especially in children by means of the 
Eoentgen rays and the fluoroscopy Vigorous 
cutaneous friction will therefore reflexly induce 
contraction of the heart muscle. 

The physiologic opinion has been gaining 
ground that the heart muscle is itself essentially 
motor, containing in its vital qualities the essential 
principles of its own activity and not depending 
for its action upon its nervous mechanism. Em- 
bryology furnishes one of the best proofs of this 
hypothesis, viz.: that the heart beats in the em- 

* The Triton Company in New York has prepared 
salts for sale corresponding to the Nauheim Salts. 
They furnish a box containing sodium bicarbonate and 
8 cakes of sodium bisulphate, the carbonic acid gas 
being generated by the action of these 2 salts upon 
each other. 



GENERAL TREATMENT OF DISEASES OF THE HEART. 81 

bryo long before any nerve influence or fibres can 
be demonstrated in its substance. In many of my 
patients to whom the baths and the resisted move- 
ments are inconvenient, I have employed vigorous 
cutaneous friction with rough towels with most 
excellent results. As a rule, I initiate the fric- 
tions, after the patient is immersed in a bath (95° 
R) for about 10 minutes. 

LUNG GYMNASTICS. 

Twelve years ago (Sacramento Med. Times, 
Sept., 1888) I urgently recommended pneumatic 
differentiation by means of the pneumatic cabinet 
as one of the most efficient agents then at our com- 
mand, in overcoming the symptoms of cardiac fail- 
ure, especially those dependent on an embarrassed 
pulmonary circulation. Time has in no wise mod- 
erated my views. The disadvantages attending this 
method are the cost of a pneumatic cabinet and 
the difficulty of its transportation. Eesults nearly 
as good may be attained by breathing exercises, 
systematically and persistently pursued. So com- 
petent an authority as Quimby (Boston Med. and 
Surg. Journal, Aug. 31, 1899) avers, "There is no 
therapeutic measure (referring to valvular lesions) 
whose action is so definite or constant." 

The heart, like any other muscle, owes its vigor 
to the activity of respiration. The exceptional 
muscular strength of insects is no doubt due to the 
fact that they respire from nearly every part of 



DISEASES OF THE HEART. 



their bodies. Individuals with organic heart dis- 
ease enjoy the best health when they are able to 
live in open air life. The principles of the "open 
air method" in the treatment of phthisis are equal- 
ly applicable in organic heart disease. The excel- 
lent therapeutic results with iron in organic heart 
disease depend no doubt on the amount of oxygen 
conveyed to the tissues. As a prophylactic against 
myocardial degeneration, the value of an assimi- 
lable iron preparation cannot be praised too high- 
ly. Owing to the negative intra-thoracic pressure 
occurring during inspiration, the blood is facili- 
tated in its flow to the chest and the effect is en- 
hanced, the deeper the respiratory movement. 
Outside of the pneumatic cabinet, I know of no 
more efficient lung exercise than systematic volun- 
tary forced inspirations and expirations, the move- 
ments of the thorax being unrestrained by cloth- 
ing. 

I have already reported (Medical Fortnightly, 
Sept., 1899) the results of my investigations with 
different methods and different apparatus in lung 
development. This was done while the Eoentgen 
rays were traversing the thorax, the index of lung 
inflation, being the bright reflex as seen with the 
fluorescent screen. The investigations in brief 
demonstrated most emphatically that deep volun- 
tary inspirations and expirations secured the most 
thorough lung inflation. 



GENERAL TREATMENT OF DISEASES OF THE HEART. 00 

METHOD OF OERTEL. 

This method aims in strengthening the heart 
muscle by exercise, diet and limitation of the in- 
gestion of fluids. It is especially applicable in the 
treatment of "fat heart." The exercise is begun 
by directing the patient to walk on level ground a 
definite distance. The appearance of fatigue, dys- 
pnea, or heart symptoms, indicates the degree of 
toleration, when walking is suspended and the 
patient must rest. It is advisable to instruct the 
patient to walk on some thoroughfare traversed by 
a street car, thus enabling the patient to ride home 
on the advent of fatigue. On the following day, 
the distance in walking is to be increased until 
finally a walk of a mile or two can be taken each 
day without inconvenience. Later, the patient, un- 
der the same precautions, is instructed to climb 
hills, climbing a certain distance each day, until, 
eventually, the top of the hill is attained without 
sense of fatigue. The diet is practically that which 
is applied in the treatment of obesity. The quan- 
tity of fluids taken must be diminished and the 
tissue fluids must be eliminated by exercise and 
sweat baths. 

HOME EXEECISE. 

When the Nauheim or Oertel methods cannot 
be conveniently taken, home exercise by means of 
springs or pulleys in which resistance can be ac- 
curately gauged may be recommended, always ac- 



84 DISEASES OF THE HEART. 

companying advice with the injunction, that exer- 
cise must always stop short of fatigue or heart 
distress. 

Treatment of Individual Symptoms. 

1. Palpitation. 2. Dyspnea. 3. Dropsy. 4. 
Cough. 5. Hemoptysis. 6. Nervous Symptoms. 
7. Gastric Complications. 8. Eenal Complica- 
tions. 

palpitation. 

Eelief should be attempted by the application of 
an ice-bag over the heart. At the same time, bro- 
mide of potassium may be given in 30-grain doses 
every 4 hours until relief is obtained. The latter 
drug has often a phenomenal regulatory influence 
on the heart and circulation, and its action is evi- 
denced by the rapid reduction in the number of 
pulse beats. It also combats the nervous irrita- 
bility so frequent in cardiac patients. Tincture of 
aconite (U. S. P.) in 1 to 3 minim doses every 3 
hours, carefully watching its effects, is often of 
great value. Under its influence, the heart-beats 
become greatly reduced in number and power, the 
pulse slow, irregular and weak. Aconite is of un- 
doubted value in functional cardiac disturbances, 
but when the heart is weak it must be used with 
circumspection, or better not at all. The further 
treatment of this symptom will be discussed under 
the treatment of special 



GENERAL TREATMENT OF DISEASES OF THE HEART. 85 
DYSPNEA. 

Here treatment must be directed to the cause: 
cardiac dilatation, bronchitis, pulmonary conges- 
tion and hyclrothorax. The latter complication is 
frequently overlooked in cardiac dyspnea. Dyspnea 
of a paroxysmal character is practically nought 
else but cardiac asthma, for which amyl nitrite 
inhalations or nitro-glycerin internally may prove 
of service. When everything else fails, reliance 
can always be placed on satisfactory doses of mor- 
phin given hypodermically. Inhalation of oxy- 
gen as a palliative measure may be tried, but un- 
less speedily effective, it is useless. 

DKOPSY. 

Beside the usual cardiac tonics which augment 
the resorption of fluids, recourse must be had to 
diuretics, purgatives and sudorifics. "We must 
never forget that cardiac dropsy always offers an 
increased resistance to the heart, and must there- 
fore be gotten rid of as soon as possible. Cardiac 
asthma and lung edema are often marvelously re- 
lieved by agents which cause a resorption of the 
edematous fluid, digitalis fulfills the double func- 
tion of cardiac tonic and diuretic. I make fre- 
quent use of the following formula: 

Infusion of digitalis 8 ounces. 

Diuretin 4 drams. 

A tablespoonful three times a day for an adult. 

A combination of strychnin, digitalis, spartein, 



DISEASES OF THE HEART. 



squill and caffein will often augment diuresis. An- 
other excellent combination is the following: 

Acetate of potash 8 drams. 

Infusion of digitalis 8 ounces. 

A tablespoonful three times a day for an adult. 
Trousseau's diuretic wine is often useful: 

Bruised juniper berries 10 drams. 

Powdered digitalis 2 drams. 

Powdered squill 1 dram. 

Sherry wine 1 pint. 

Macerate for four days and add: 

Potassium acetate 3 drams. 

Press and filter. 

A tablespoonful three times a day for an adult. 
Calomel often proves to be an excellent diuret- 
ic in cardiac dropsy, even when digitalis fails. Dur- 
ing its use, the excretion of urine becomes very 
large. When calomel fails in its action, we must 
be on the lookout for mercurialism. 

Calomel is given in 2 or 3 grain doses combined 
with opium (gr. 1-6), 3 times a day. The addition 
of the latter is to overcome the tendency to 
diarrhea. Mercurialism is prevented by mouth 
hygiene. If at the end of five days increased 
diuresis does not occur, or if at any time during its 
use salivation arises, the drug must be suspended. 
The diuretic action of calomel is not usually man- 
ifest until the third day. 

Galactotherapy. — Skimmed milk, 2 to 3 quarts 
daily is followed in a few days by augmented diu- 



GENERAL TREATMENT OF DISEASES OF THE HEART. 87 

resis. If, after five days, the latter symptom is 
not manifest, it will usually fail. The ordinary 
diet must be taken in conjunction with the milk, 
as it is doubtful whether an exclusive milk diet 
can provide sufficient nourishment for an adult, 
a fact of great importance where nutrition is of 
such vital importance in the restoration broken 
compensation. 

Purgatives. — The method of Hay is useful: 
Eochelle or Epsom salts (1 to 1^ oz.) in concen- 
trated solution, taken one hour before breakfast, 
is followed by 3 to 6 watery evacuations daily. 
When salines fail and the heart is strong, drastic 
purgatives like the following may be used. Pulvis 
jalapse comp. (3 gr. to 1 oz.), resina scammonii (5 
to 10 gr.), extraction colocynthidis comp. (5 to 10 
gr.), resina podophylli (1 to | gr.), elaterin (Merck), 
(1-20 to 1-12 gr.). 

Sudorifics. — Pilocarpine is the ideal diaphoretic, 
but on account of its deleterious action on the 
heart, should never be used. Instead, the hot 
bath, of 15 minutes' duration, after which the 
patient is wrapped in blankets, may be used. The 
hot air bath is often more convenient. The hot air 
may be conducted through a tube under the bed- 
clothes raised under a low cradle. Sweat baths are 
usually well tolerated, although before using, the 
patient should be stimulated by whisky. 

Relief of Dropsy by Surgical Means. — When 



00 DISEASES OF THE HEART. 

medicines fail, punctures through the skin to the 
subcutaneous tissue of the lower extremities should 
be made. A sterilized scalpel is usually employed 
for making the punctures, although a large-sized 
needle is equally useful. This method has fallen 
into disuse owing to wound infection following 
the punctures. To avoid infection, Southey sug- 
gested using fine silver trocars, with rubber tubes 
attached, so that the fluid could run off gradually. 
In this way, a few pints of edematous fluid may be 
disposed of in a day. After the incisions are made, 

1 frequently employ a cupping glass to facilitate 
the removal of the fluid. Danger of infection is 
done away with entirely, if the physician conducts 
his minor surgery under the strict principles of 
asepsis. The skin to be punctured or incised is 
scrubbed and then washed with an antiseptic. 
Then with an aseptic scalpel, four small incisions 
are made on either side of the leg and immediately 
covered with borated cotton. The latter must be 
constantly renewed, when wet, by sterilized hands. 
With the patient in the sitting posture, the flow of 
fluid is greater. To facilitate the rapid removal 
of fluid, I often use the following method: Two 
incisions are made on either side of the thigh 
above the knee joint; then a Martin elastic band- 
age is applied beginning at the foot and extended 
upward to an inch below the incisions. The band- 
age forces the fluid toward the incisions. 



GENERAL TREATMENT OF DISEASES OF THE HEART. 89 
COUGH. 

This is a common symptom and frequently re- 
sults from stasis in the pulmonary vessels with 
concomitant bronchial catarrh. Treatment di- 
rected toward incompensation is indicated. Codein 
may be tried, although heroin in tablets., 1-20 to 
1-12 gr., several times a day has given me the best 
results. 

HEMOPTYSIS. 

This rarely calls for treatment. It is often a 
relief to the congested pulmonary vessels, and is 
rarely fatal. The all-important treatment when 
indicated is absolute rest in bed. 

No faith is to be placed on the conventional 
hemostatics. The most reliance to be placed in 
the hypodermic use of morphin. Gelatin in solu- 
tion introduced subcutaneously, may be tried. In 
a recent patient with intractable hemoptysis, large 
quantities of flavored gelatin taken by the mouth 
proved efficacious. A similar experience was had 
in two cases of purpura hemorrhagica. 

KERVOUS SYMPTOMS. 

For the insomnia and peculiar hallucinations of 
cardiopathic patients, paraldehyd and trional give 
excellent results. A dose of spirits of chloroform 
or ether in hot whisky will often give a quiet 
night. Chloral should not be used. Hydrothera- 
peutic measures may be tried, such as bathing the 



90 DISEASES OF THE HEART. 

face with cool water, an alcohol sponge or a wet 
pack with warm water. When everything else 
fails, morphin, hypodermically, may always he 
depended on. 

GASTKIC COMPLICATIONS. 

Stomach disturbances are oftentimes only re- 
lieved when compensation is restored. Until this 
occurs, little burden should be thrown on the 
stomach by careful dieting. A milk diet will often 
bridge over a period of gastric irritability. Starchy 
foods cause flatulency and must be proscribed. 
Concentrated meat extracts may be tried. They 
are easily absorbed, nutritious and stimulating to 
the heart. Of late I have used tropon, which 
represents over 90 per cent of pure albumin. It 
is insoluble in water and may be given in soup or 
with the yolk of an egg. It is not palatable. 

RENAL COMPLICATIONS. 

In renal complications, diet is of prime import- 
ance. Foods must be selected which are capable 
of easy digestion, and which are least liable to 
produce intestinal poisons and thus conduce to 
auto-intoxication. Arterial tension being high in 
these cases, nitrogenous food and fermented liquors 
should not be used. Pre-digested milk is the ideal 
food relieved by kumyss. A vegetable diet, ex- 
cluding fibrous vegetables, such as turnips, beets, 
etc., and beans and asparagus, combined with fresh 



GENERAL TREATMENT OF DISEASES OF THE HEART. 91 



fruits, is useful. When digitalis is used, it should 
be employed in conjunction with nitro-glycerin. 
The uric acid diathesis must be remembered as a 
common cause of high arterial tension, and the 
appropriate treatment must be directed toward the 
formation of uric acid and its excretion from 
the economy. 



CHAPTER IV. 

AFFECTIONS OF THE PERICARDIUM. 

Acute Plastic or Fibrinous Pericarditis, 
etiology. 

Rarely primary, as a result of traumatism. 
Usually secondary to the acute infectious diseases. 
Acute rheumatism is the chief etiologic factor in 
about 50 per cent of the cases. Especially in chil- 
dren, pericarditis may precede the joint symp- 
toms. Next to the rheumatic, tuberculous peri- 
carditis is the most frequent variety. The 
disease frequently complicates the septic processes. 
It may be one of the earliest symptoms of Bright's 
disease especially the interstitial farm (pericardite 
Brightique, of the French). Gout, scurvy, can- 
cer and leukemia are causes. From the contigu- 
ous tissues and organs, inflammation by extension 
may implicate the pericardium. 

PATHOLOGY. 

The exudation consists mainly of fibrin. Fluid 
may be present but never in large amounts. The 
superficial layers of the heart muscle may become 
implicated in the inflammatory process thus en- 
tailing cardiac asthenia which will gravely influ- 
ence the prognosis. 



AFFECTIONS OF THE PERICARDIUM. 93 

SYMPTOMS. 

No reliance must be placed on subjective symp- 
toms, otherwise, the affection will, as it often is, 
be overlooked. Pain referred to the precordia or 
xiphoid cartilage may be present. The most trust- 
worthy sign is the friction sound. It may be 
palpated but is more often heard. 1. It is a rub- 
bing, scratching sound and appears to be quite 
superficial. 2. It is best heard over the right ven- 
tricle, the part of the heart approaching nearest 
the chest wall, viz., the fourth and fifth inter- 
spaces and neighboring parts of the sternum. 3. 
It is not, like the endocardial murmur, transmit- 
ted away from the heart 4. Its intensity varies 
with the position of the patient. 5. It is usually 
double, corresponding with both systole and dias- 
tole, but the synchronism with the heart tones is 
not absolute. One receives the impression that it 
is a superadded sound. I have frequently found 
that the rubber tip of the stethoscope will often 
create adventitious sounds not unlike the friction 
murmur. To obviate this error, my modified 
stethoscope illustrated in a previous chapter will 
be found useful. With it, one may make pressure 
in an intercostal space and thus accentuate the 
murmur to a marked degree. The ordinary pa- 
nendoscope is not available for such a purpose, as 
the least degree of pressure creates artificial 
sounds. 



94 



DISEASES OF THE HEART. 



DIAGNOSIS. 

For differentiation from other friction sounds, 
vide chapter on diagnosis. 

COURSE AND TERMINATION. 

Usually favorable to life. Eheumatic cases usual- 
ly recover. The exudate may agglutinate the peri- 
cardial layers (adhesive pericarditis) or the plastic 
variety may be converted into a pericarditis with 
effusion. 

TREATMENT. 

Symptomatic and expectant. Eoutine measures 
are not justified. One is reminded of the story 
told of Sir Wm. Gull. At a consultation, the lat- 
ter detected a pericarditis which had been over- 
looked. The attending physician was unduly 
apologetic for his oversight. Sir William replied, 
"Perhaps it is just as well you did not find it, for 
if you had, you might have treated it." Absolute 
rest in bed is generally demanded to reduce to a 
minimum the action of the heart. An ice bag to 
the precordia relieves pain and palpitation. Hot 
applications may prove more efficient. Blisters to 
the precordia, an old time practice, is not justified 
by modern knowledge. Their application interfere 
with a close study of the heart. Small doses of 
digitalis or strophanthus may be indicated to con- 
trol the excited heart's action or when the pulse 
becomes irregular, intermittent and of low tension. 



AFFECTIONS OF THE I'KRlCARDIUM. 



Pericarditis With Effusion. 



A common sequence of the previous variety. 
About one-third of the cases are associated with 
acute rheumatism. Phthisis, septicemia and 
Brighfs disease are among the etiologic factors. It 
may complicate the eruptive fevers or depend on 
an extension of inflammation from contiguous 
strictures. 

PATHOLOGY. 

The effusion is usually sero-fibrinous but may 
be hemorrhagic or purulent. The quantity of fluid 
may vary from six ounces to four pints. The peri- 
cardial layers are thickened and covered with fib- 
rin. In favorable instances, absorption of the fluid 
occurs. As a rule, the fluid only is absorbed, the 
fibrinous exudate remaining to form adhesions be- 
tween the visceral and parietal membranes. In 
the severe forms the superficial layer of the heart 
muscle beneath the visceral pericardium becomes 
functionally and anatomically involved. (Peri- 
myocarditis.) 

SYMPTOMS. 

No affection is more frequently overlooked. It 
may develop without symptoms. Pain and dis- 
tress in the precordia may be the earliest symp- 
toms. Pressure symptoms depend on the amount 
of the effusion. 



DISEASES OF THE HEART. 



Dyspnea or orthopnea is an early symptom of 
pressure. 

Aphonia, due to compression of the recurrent 
laryngeal as it winds round the aorta, dysphagia, 
from pressure on the esophagus, irritative cough, 
from compression of the trachea, distension of the 
veins of the neck and compression of the left lung 
are other pressure signs. Altered cardiac rhythm 
due to the mechanic effects of the fluid on the heart 
interfering with its action is common. The pulse 
is rapid, intermittent and small. The paradoxical 
pulse may be present, i. e., a pulse in which the 
beats become weak or lost with each inspiration. 

When the effusion is not large, a very important 
rational sign to remember is, that the apex beat 
which is with difficulty palpated, may be associated 
with a comparatively strong pulse. 

The onset of the disease may be characterized by 
cerebral symptoms. The patient is delirious or 
may become melancholic and show suicidal tenden- 
cies. The condition may resemble delirium tre- 
mens. The occurrence of delirium in acute rheu- 
matic fever should at once direct attention to the 
heart. 

PHYSICAL SIGNS. 

Inspection and Palpation. In young subjects, 
there is precordial prominence with obliteration 
and even bulging of the intercostal spaces. The 
apical beat is diffused or lost and if felt, is raised 



AFFECTIONS OF THE PERICARDIUM. 97 

and dislocated outward. Adhesions of pericardial 
origin may retain the apex to the chest wall de- 
spite the effusion. Ewart's sign, in which it is 
possible to feel the upper edge of the first rib to- 
gether with its inspiratory and expiratory move- 
ments is regarded as trustworthy although it also 
occurs in some cases of heart dilatation. 

Percussion. This is to be relied on most in diag- 
nosis. The precordial figure of dullness is ir- 
regularly pear shaped; the base directed down- 
ward and the stem or apex directed toward the 
upper end of the sternum. 

Sternal dullness is a suggestive sign. Normally 
the sternum is resonant owing to the contact of its 
upper part with the lungs. When this contact 
ceases to exist, as occurs in pericardial effusion 
when the lungs are separated from the sternum, 
percussion of the latter bone will yield dullness. 
This sign cannot be regarded as diagnostic because 
an enlarged heart may have the same effect on the 
lungs. 

The Eotch sign is important in diagnosis. As 
a result of effusion within the right corner of the 
pericardial sac, the usually resonant area in ques- 
tion may become dull on percussion. This area is 
in the right fifth inter cartilaginous space formed 
by the right border of the heart and right lobe of 
the liver (cardio-hepatic triangle). Dullness of 
the triangle has been observed, though rarely, in 



98 DISEASES OF THE HEART. 

cases of enormous dilatation of the right auricle 
from tricuspid stenosis. 

Depression of the liver is more marked in peri- 
cardial effusions than in any other intra-thoracic 
affection, the possible exception being pneumo- 
thorax. The hepatic percussion note may begin at 
the level of the tip of the xiphoid instead of at 
the infra-sternal notch. As a result of the depres- 
sion, the fingers applied below or at the side of the 
xiphoid can be made, by pushing upwards and 
backwards, to ride over the upper surface of the 
liver, which is normally out of reach. 

The posterior pericardial patch of dullness in 
association with other symptoms furnishes a com- 
plete and crucial evidence of fluid. Whenever fluid 
accumulates in the pericardium, a marked patch 
of dullness is found at the left inner base, extend- 
ing from the spine for varying distances outward. 

The Eespiratory Sign. I have designated this 
the respiratory sign because the area of precordial 
dullness is dependent on the amount of air in the 
lungs. Normally it is possible to obliterate the 
superficial area of cardiac dullness by deep in- 
spiration. Even in extreme cases of cardiac dila- 
tation, the area of heart dullness may be dimin- 
ished by forced inspiration. In effusions, the in- 
fluence of forced inspiration is extremely slight 
or absent. 

Auscultation. The heart tones are feeble or dis- 



AFFECTIONS OF THE PERICARDIUM. 99 

taut and scarcely heard. The friction sound heard 
in the beginning may disappear but often persists 
at the base or perhaps at a limited area of the 
apex. An important sign, if the patient is seen 
early, is to note the diminishing loudness of the 
heart tones with increasing effusion. 




Fig. 9 — Illustrating "Rotch's sign" (dullness in the 
right 5th space — 5 to H); also contrasting the angle 
(on either side of H) of the dullness as due respectively 
to effusion and to dilatation. The heart's outline is nor- 
mal in size and position. The outer lines are those 
of the dullness in moderate effusions. 'The "supra- 
hepatic line" (dotted) and the "hepatic line" limit the 
normal "modified" dullness of the liver; and H is 
placed on the absolute dullness. — (Ewart.) 

Bamberger's Sign. When the patient is sitting 
upright an area of dullness about the size of a 
silver dollar can be detected at the angle of the 
scapula. On auscultation of this area, tubular 
breathing is heard. If the patient leans forward, 

L.cfC. 



100 



DISEASES OF THE HEART. 



dullness and tubular breathing disappear but re- 
appear when the erect posture is again maintained. 
A valuable sign. 

The Roentgen rays. Guided by my individual 
experience, I know of no means simpler and at- 
tended with less danger of error than the X-rays. 
By their aid, one is able to map out the contour 




Fig.io — The posterior pericardial patch of dullness 
sign (shaded) and Bamberger's sign (T A). The pos- 
terior pericardial patch of dullness is shaded. T A — 
Posterior patch of tubular breathing and egophony. 

of the heart in its entirety. One can always de- 
tect in the normal heart some movement especially 
in the left ventricle. Such movements are not 
discernible in effusions but it may happen that an 
evanescent wave transmitted to the fluid by the 
heart may lead to an error in diagnosis. If, how- 



AFFECTIONS OF THE PERICARDIUM. 101 

ever, one provokes the heart reflex, the danger of 
misinterpretation is reduced to a minimum. The 
reflex is a phenomenon observed by means of the 
X-rays. It is a momentary contraction of the 
heart muscle upon application of an irritant to the 
skin of the precordia. Stroking the skin with a 
lead pencil or the finger nail suffices to call forth 
the reflex. The elicitation of the reflex is impossi- 
ble in effusion. 

DIAGNOSIS. 

There are three characteristic signs of a peri- 
cardial effusion. 1. The apex beat located by pal- 
pation or auscultation is found an inch or two 
within the left border of precordial dullness. 2. 
The cardiac impulse is feeble and appreciated with 
difficulty. 3. The feeble and distant heart tones 
are in marked contrast with a comparatively strong 
radial pulse. 4. The shape of the figure of pre- 
cordial dullness. 

Dilatation of the heart offers the greatest draw- 
back in differential diagnosis. The following facts 
are in favor of heart dilatation. 

1. Previous history of valvular heart disease. 

2. Absence of fever, pain and pressure symptoms. 

3. The heart impulse is usually visible and wavy 
and the apex beat is visible and diffused. The 
shock of the cardiac tones may be felt 4. The area 
of dullness rarely assumes the triangular form, nor 
does it excepting in metral stenosis reach so high 



102 



DISEASES OF THE HEART. 



or so low without visible or palpable impulse. 5. 
The tympanitic tone in the axillary region owing 
to lung compression often present in effusion is 
absent in heart dilatation. 6. The heart sounds 
are clear and sharp and there is no friction 
murmur. 

CHARACTER OF THE FLUID EXUDATE. 

In rheumatism, the exudate is usually sero-fib- 
rinous, purulent in septic and tuberculous cases; 
hemorrhagic in nephritic, tuberculous and senile 
individuals. The only positive means of deter- 
mining the nature of the fluid is by aspiration 
(paracentesis pericardii). This may be done with 
an hypodermic needle under aseptic conditions. 
The following points of election may be chosen, 
preference being given to the first : 1. Fifth left 
intercostal space, an inch and a half from the 
edge of the sternum. 2. Lower left part of the 
pericardial sac just within the margin of dullness. 
3. Left costo-xiphoid angle. When the needle has 
entered the pericardial sac, suction is used. Punc- 
ture of the heart has repeatedly occurred without 
any special danger and only one fatal case has been 
reported. To avoid damage to the heart, the use 
of a trocar and canula has been suggested. A sin- 
gle aspiration with negative results is not sufficient 
to exclude fluid when the physical signs are strong- 
ly suggestive of its pressure. 



AFFECTIONS OF THE PERICARDIUM. 103 

COUESE AND TERMINATION". 

The course of an effusion may be controlled by 
demarcating the figure of dullness by means of a 
nitrate of silver pencil. Sero-fibrinous effusions 
may reach a maximum in forty-eight hours and 
are often absorbed with equal rapidity. When the 
effusion lasts weeks, it is referred to as chronic. 
Sero-fibrinous effusions usually undergo absorption 
although pericardial adhesions remain. Cases that 
tend to a fatal end are marked by pressure symp- 
toms; increasing dyspnea, cyanosis and failing 
circulation. Nervous symptoms are of grave im- 
port and unless they remit, death may occur within 
ten days. When a large effusion persists for weeks, 
death may result from cardiac asthenia. Etiology 
influences the prognosis, rheumatic pericarditis 
tends to recovery, whereas the tuberculous form is 
as a rule fatal. 

TREATMENT. 

The essential object is to aid absorption of the 
fluid. A variety of methods have been suggested : 
Blisters to the precordia are warmly recommended 
by Osier. Purges and diuretics may be tried. 
Iodide of potash and digitalis are employed. De- 
pressing measures are always contra-indicated. 
Diaphoretic methods are used. Sodium salicylate 
has often a very favorable action in hastening ab- 
sorption. Pilocarpin has been recommended but 
its use must be preceded by large dose of some 



104 DISEASES OF THE HEART. 

alcoholic to prevent collapse symptoms. When 
these methods fail or when death is imminent from 
cardiac pressure, indicated by increasing dyspnea, 
cyanosis and small rapid pulse, procrastination is 
fatal and recourse must be had to tapping. Punc- 
ture is usually made in the fifth interspace an inch 
and a half from the left sternal margin with the 
strictest asepsis and the amount of liquid with- 
drawn should not exceed 2-3 ounces at any one 
time. It is wiser to repeat the puncture several 
times rather than to remove the pressure too sud- 
denly from the heart. If possible, the patient 
should be tapped in the recumbent position, for in 
this decubitus, the heart being heavier than the 
fluid sinks toward the back and is out of reach of 
the needle. In addition to aspiration, some writers 
recommend the subsequent injection of iodin dis- 
solved with potassium iodide in water. Aspira- 
tion is generally successful if not too long delayed. 

PUKULENT PERICAKDITIS. 

This form is characterized at the onset by fre- 
quently recurring rigors, intermittent type of 
fever, early prostration and a rapid and unfavor- 
able course. The etiology and symptomatology 
suggest the character of the fluid and aspiration 
proves it. 

The treatment is essentially surgical. Paracen- 
tesis is not sufficient to cure it. Incision and 
drainage are essential and should not be delayed. 



AFFECTIONS OF THE PERICARDIUM. 105 

The prognosis is comparatively good after pericar- 
diotomy for pyopericardium. Eoberts collected 26 
cases, showing 10 recoveries and 16 deaths. Of the 
fatal cases, 9 were septic, and all the others which 
died had severe complications. 

Chronic Adhesive Pericarditis. — x\dherent 
Pericardium. 

etiology and pathology. 
Eesults from the acute form. The adhesions 
(synechia) may be partial or general leading to 
complete obliteration of the pericardial sac. The 
outer surface of the pericardium may become ad- 
herent to the pleura, chest wall or mediastinal tis- 
sues. The heart muscle shows atrophic and degen- 
erative changes. 

SYMPTOMS. 

Inspection and Palpation. Eetraction of the 
interspaces and even the ribs at the time of systole 
of the ventricles. Dislocation of the apex outward 
and increase of the area of impulse caused by the 
cardiac hypertrophy which frequently complicates 
the synechia. A quick rebound, known as the 
diastolic shock occurring after systole is regarded 
as characteristic. Collapse of the cervical veins 
(sign of Friedreich) occurs during diastole of the 
heart. Inspiratory swelling of the veins of the 
neck (sign of Kussmaul) may be observed. The 
pulsus paradoxus is sometimes present. It is a 



106 DISEASES OF THE HEART. 

pulse small and feeble during inspiration and gains 
strength and volume during expiration. 

Percussion shows increase in cardiac dullness 
especially upward and to the left. When pleural 
adhesions complicate the trouble, the area of car- 
diac dullness is not diminished when the patient 
takes a deep breath. 

Auscultation may reveal the signs of dilatation 
or hypertrophy. 

TREATMENT. 

This concerns itself with the nutrition of the 
heart muscle on the lines indicated in the treat- 
ment of valvular lesions. The embarrassed heart 
may stop suddenly in fatal syncope or pass through 
the stages of broken compensation. 

Mediastino-Pericarditis. 

etiology and pathology. 
Occurs most frequently in young adults and 
males from an extension of the pericardial inflam- 
mation to the anterior mediastinum. The pericar- 
dium is thickened and adherent to the structures 
in the anterior mediastinum. 

SYMPTOMS. 

Dyspnea, cyanosis, venous engorgement, liver 
enlargement, ascites and anasarca. The physical 
signs are those of adherent pericardium. The 
mediastinal friction, systolic in time, heard over 



AFFECTIONS OF THE PERICARDIUM. 107 

the sternum and increased in intensity when the 
arm is raised has been observed by Perez. 

Hydropericardium. — Dropsy of the Pericar- 
dium. 

etiology and pathology. 

The occurrence of fluid in the pericardium with- 
out inflammation of the serous sac. The serous 
transudate is secondary and associated with cardiac 
or renal dropsy when other serous cavities are sim- 
ilarly occupied by fluid. Fluid may accumulate 
suddenly in nephritis especially in the scarlatinal 
form. Intra-thoracic mechanical causes may con- 
tribute to the accumulation of a non-inflammatory 
fluid in the pericardium. When the serum has a 
milky character it is known as chylo-pericardium. 

The symptoms are those of effusion without 
fever or friction murmurs. The treatment is that 
indicated in general dropsy although aspiration 
may be necessary. 

HEMOPERICARDIUM. 

The causes are: Eupture of the first part of 
the aorta, the coronary arteries or the heart. 
Wounds of the heart and pericardium are further 
causes. Death may occur before symptoms de- 
velop especially in ruptured aneurisms. In tu- 
berculosis and cancer, the effusion may be blood- 
stained and must not be regarded as instances of 
hemopericardium, Death results from heart fail- 



108 DISEASES OF THE HEART. 

ure, the result of compression. Aspiration has 
been successful in a limited number of traumatic 
cases. 

PNEUMOPERICARDIUM. 

Air or gas in the pericardial sac is rare and is 
caused generally by perforated thoracic wounds 
or the result of perforation from the lungs, sto- 
mach or esophagus. Decomposition of pus in the 
sac may develop gases. When pus is present, we 
speak of a pyo-pneumopericardium. The physical 
signs are those yielded by the pressure of fluid and 
gas. Percussion gives a movable arc of dullness 
by altering the patient's posture with a tympanitic 
sound in the region of the gas. The heart sounds 
on auscultation assume a metallic splashing char- 
acter. Death rapidly occurs unless the trouble is 
caused by perforation from without. 

Treatment is indicated in the latter instance by 
enlargement of the wound and free incision. Air 
is sometimes spontaneously absorbed as in pneu- 
mothorax. 



CHAPTER V. 

ENDOCARDITIS AND CHRONIC 

VALVULAR DISEASE. 

Endocarditis, 
etiology and pathology. 

Inflammation of the lining membrane of the 
heart is usually confined to the valves and is gen- 
erally a secondary infection in the course of vari- 
ous diseases. The pathologic antecedent is gen- 
erally acute articular rheumatism, the etiologic 
elements of which have not yet been established. 
The arthritic phenomena may be secondary to the 
endocardial inflammation. When secondary to 
erysipelas, the streptococcus pyogenes may be dem- 
onstrated. In the suppurative processes, like py- 
emia and puerperal fever strepto and staphylococci 
are found. Endocarditis following croupous pneu- 
monia and pulmonary tuberculosis is not uncom- 
mon. Osier in 100 autopsies in pneumonia cases 
found it present in 5 instances and in 216 necrop- 
sies on phthisical cases, it was present in 12 in- 
stances. Diphtheric endocarditis is not frequent 
and the same statement applies to typhoid endocar- 
ditis which is caused by the typhoid bacillus. 

In gonorrheal endocarditis which is not infre- 
quent, the gonococcus has been frequently demon- 



110 DISEASES OF THE HEART. 

strated in the endocarditic vegetations. In the 
endocardial inflammation complicating acute 
nephritis, the micro-organisms concerned in pro- 
ducing the nephritis are the exciting agents. 

Pathologically the different forms of endocardi- 
tis are characterized as follows : Simple acute 
endocarditis shows the presence of minute vege- 
tations on the valves of a warty appearance. These 
vegetations may be absorbed, result in the produc- 
tion of an ulcer or end in chronic valvulitis with 
deformity. 

Malignant or ulcerative endocarditis is charac- 
terized by rapidly occurring ulceration of the 
valves, heart septum or the heart itself. Suppu- 
ration may complicate the ulceration. 

Chronic Endocarditis is an interstitial inflam- 
mation of the heart valves leading to deformity 
of the valve segments. It is a slow process and is 
the usual cause of chronic valvular disease. Syph- 
ilis, gout, alcoholism and prolonged muscular ex- 
ertion are the usual causes. 

DIAGNOSIS. 

Simple Endocarditis. The subjective symp- 
toms are usually negative. The physical signs are 
alone conclusive. In the course of an infectious 
disease, cardiac complication is betrayed by pal- 
pitation and irregularity of the heart. 

The physical signs are evident by auscultation. 
Murmurs or roughened heart sounds may be pres- 



ENDOCARDITIS AND CHRONIC VALVULAR DISEASE. Ill 

ent. Very frequently the physical signs are dubi- 
ous. The occurrence of fever of moderate range 
(100-102 deg. F.) together with a murmur over 
one of the heart orifices with perhaps irregularity 
in the organ speak for endocarditis. One must not 
mistake the soft bellows murmur often heard in 
acute febrile diseases usually heard over the aortic 
area with the murmurs occurring in endocarditis 
which are best heard over the mitral area. 

Malignant endocarditis presents two distinct 
types, the septic or pyemic and the typhoid. The 
septic type associated with wounds and septic pro- 
cesses is characterized by chills, sweats, irregular 
fever and the usual phenomena of septic infection. 
This type has been known to be frequently mis- 
taken for intermittent fever. 

The typhoid type is more frequent than the 
former and is manifested by irregular tempera- 
ture, delirium, prostration, coma, diarrhea and 
sweating. Petechial rashes and erythema are com- 
mon in both types as well as embolic phenomena. 
The emboli take their origin from the soft vege- 
tations on the valves and are carried to the differ- 
ent organs. When the emboli go to the brain, de- 
lirium, coma, aphasia or hemiplegia results; to 
the kidney, hematuria; to the spleen, local peri- 
tonitis; to the skin, minute hemorrhages. 

The physical signs are notoriously uncertain. A 
murmur may or may not be present. A murmur 



Il2 DISEASES OP THE HEART. 

varying in character from day to day is charac- 
teristic of malignant endocarditis. Malignant en- 
docarditis may develop in consequence of infection 
on an old valvular heart lesion. The diagnosis is 
easy when embolic phenomena occur associated 
with irregular fever, profound prostration and the 
presence of heart symptoms. 

DIFFERENTIAL DIAGNOSIS. 

From malaria, endocarditis of a malignant type 
may be excluded by an examination of the blood. 
From cerebro-spinal fever, we must rely on the 
preponderance of cardiac symptoms. From ty- 
phoid fever, with which disease it is most frequent- 
ly confounded, the following symptoms speak 
against typhoid fever and for malignant endocar- 
ditis; history of rheumatism, pneumonia or some 
infectious disease, no prodromata, onset marked 
by a severe chill, rapid rise of temperature of an 
irregular type, profound prostration early, embolic 
symptoms (hemiplegia, aphasia, hematuria, etc.), 
cardiac symptoms (loud systolic murmur), septic 
leucocytosis. 

Chronic Endocarditis manifests itself by the 
presence of symptoms peculiar to chronic valvular 
disease which will be considered under special 
lesions of the valves. 

COURSE AND TERMINATION. 

In simple acute endocarditis, there is rarely any 
immediate danger, the prognosis depending on the 



ENDOCARDITIS AND CHRONIC VALVULAR DISEASE. 113 

character of the primary disease. As a rule, this 
form of endocarditis is the initial factor in the 
development of permanent valvular lesions of the 
heart. In malignant endocarditis the prognosis 
is likewise dependent on the primary disease. Un- 
less grafted upon a chronic valve lesion, the dis- 
ease rapidly tends toward a fatal termination, the 
course rarely lasting more than six weeks, where- 
as in some instances, the disease may terminate 
fatally in a few days. In one of my patients with 
gonorrheal endocarditis, the disease lasted only 
three days. It was marked by emboli which com- 
pletely cut off the circulation in three of the fin- 
gers of one hand. In the chronic form, the prog- 
nosis is that of the individual lesions of the valves. 

TREATMENT. 

No measures are yet known by which endocardi- 
tis can be prevented although absolute rest in bed 
and protection of the body against cold in the 
specific fevers, may diminish the tendency to the 
disease. The value of the salicylates in rheuma- 
tism while undoubted have little influence in pre- 
venting endocarditis. We have no remedy which 
will directly influence the endocarditis, although 
something may be done in the way of symptomatic 
treatment. Rest must be enjoined in all cases and 
vascular excitement controlled by the ice bag to 
the precordia and the use of aconite. Heart fail- 
ure calls for strychnin and alcoholic stimulants, 



114 DISEASES OF THE HEART. 

while digitalis is positively contra-indicated, the 
drug causing violent cardiac contractions of an in- 
flamed and enfeebled heart. In the malignant 
form of endocarditis, antistreptococcus serum 
promises to be of some value. 

Chronic Valvular Disease. 

aortic incompetency; aortic insufficiency; 

aortic regurgitation. 

General Symptoms. If perfect compensation 
exists, there may be no symptoms. Arterial 
anemia, especially of the brain, is an early symp- 
tom and the patient complains of attacks of giddi- 
ness, is pale and suffers from dyspnea. Pains in 
the region of the precordia and radiating to the 
neck and arms occur more often in this, than in 
any other valvular lesion of the heart. 

Physical Signs. They are made up of the evi- 
dence furnished by hypertrophy of the left ven- 
tricle, viz., dislocation of the heart apex, down- 
ward outward and to the left, increased area of 
cardiac impulse, increased area of cardiac dullness, 
which is greater than in any other valve lesion, 
and which is increased downward and to the left. 
The chief sign of this lesion is obtained by auscul- 
tation; at the second right costal cartilage a dias- 
tolic murmur is heard. 

CHARACTERISTICS OF THE MURMUR OF AORTIC IN- 
COMPETENCY. 

1. It is propagated along the sternum toward 



Endocarditis and bhronic valvular disease. 115 

the apex. 2. Its point of maximum intensity may 
be the fourth left costal cartilage on the apex. 3. 
It may be heard in the vessels of the neck. 4. 
The murmur is usually soft, but sometimes rough 
and loud. 5. A systolic murmur heard in the 
aortic area is not diagnostic of aortic stenosis, it 
is more often caused by roughening of the semi- 
lunar valves or of the inner coating (intima) of 
the aorta. 6. A systolic murmur heard in the 
mitral area, associated with aortic regurgitation 
may be caused by relative insufficiency of the 
mitral opening. 

Arterial Signs. The peripheral vessels pulsate 
more often in this than in any other valve lesion. 
Double murmurs may be heard over the carotids 
and subclavians. The water hammer or Gorrigan 
pulse is characteristic, a quick and jerking pulse 
which, striking the finger, rapidly recedes. This 
pulse phenomenon is accentuated when the arm is 
elevated. The capillary pulse is obtained by draw- 
ing a line with the finger nail across the forehead. 
The hyperemia induced on either side of the line, 
becomes alternately red and pale. It is also seen 
beneath the finger nails. 

Course and Termination. The lesion may be 
compensated for years without inconvenience. 
The occurrence of heart degeneration marks the 
advent of disturbed compensation, beginning with 
precordial pain, headache, vertigo, palpitation, 



116 



DISEASES OF THE HEART. 



cardiac distress, edema and dyspnea. General 
dropsy is not common unless a mitral lesion com- 
plicates the trouble. Sudden death is more fre- 
quent in this, than in other lesions. With 
compensation failure, slight irregular fever and 
embolic phenomena due to recurring endocarditis 
terminate the scene. 

AOKTIC STENOSIS 

General Symptoms. Owing to narrowing of the 
aortic orifice the deficient systemic blood supply 
induces most frequently signs of cerebral anemia. 

The physical signs are those common to left 
ventricular hypertrophy. Palpation may de- 
tect a systolic thrill in the aortic area. Ausculta- 
tion reveals a murmur in the aortic area, systolic 
in time and transmitted along the course of the 
blood vessels. The murmur is harsh, loud and 
sometimes musical. The second sound, if re- 
gurgitation is not present may be muffled or 
absent. This is caused by stiffness or thickening 
of the valve. 

Diagnosis. A systolic murmur in the aortic 
area may also be caused by atheroma or dilatation 
of the aorta, or anemia. A murmur due to the 
first causes is often accompanied by a second sound 
which is accentuated and the small and slow pulse 
and systolic thrill are absent. The murmur of 
anemia is also accompanied by an accentuated sec- 



ENDOCARDITIS AND CHRONIC VALVULAR DISEASE. 117 

ond tone and there is no hypertrophy, thrill, or 
small pulse. Signs of anemia are present. 

Course. If hypertrophy is present, the condi- 
tion may be latent. The early signs of compensa- 
tion failure are : Dizziness, pain in the precordia 
and palpitation. 

MITRAL INCOMPETENCY; MITRAL REGURGITA- 
TION; MITRAL INSUFFICIENCY. 

General Symptoms. The effects of this lesion 
on the pulmonic and systemic circulation after 
failure of compensation is more pronounced than 
disease at any of the other orifices. As in other 
lesions, there are no symptoms if the trouble is 
compensated. When compensation fails, we have 
all the characteristic symptoms of heart disease, 
cyanosis, dyspenea, cough and expectoration, 
dropsies, etc. 

The physical signs are those of dilatation and 
hypertrophy of both chambers at the time of full 
compensation. Auscultation exists in the mitral 
area, a murmur systolic in time, transmitted to the 
left axilla and scapular angle. In accordance 
with hypertrophy of the right ventricle and conse- 
quent increased tension in the pulmonary artery, 
we hear accentuation of the second pulmonic tone. 

Diagnosis. The systolic murmur of aortic 
stenosis and tricuspid regurgitation may be mis- 
taken for mitral incompetency. 



118 DISEASES OF THE HEART. 

data speaks for aortic stenosis: The murmur is 
loudest over the base and is transmitted to the ves- 
sels of the neck, there is no accentuation of the 
second pulmonic tone, the left ventricle only is en- 
larged, the thrill if palpable is at the base of the 
heart. In tricuspid regurgitation, we have pul- 
sation of the cervical veins, pulsation of the liver, 
and the systolic murmur has its seat of maximum 
intensity at the base of the ensiform cartilage; the 
propagation of the murmur is not so extensive nor 
in the direction of the murmur of mitral incom- 
petency. We must also exercise care in dis- 
tinguishing functional murmurs from the murmur 
of incompetency. 

MITRAL STENOSIS. 

General Symptoms. Constriction of the left 
auriculo-ventricular orifice may exist for years 
without symptoms, although at any time a fresh 
endocarditis may develop and give rise to the 
phenomena of embolism in the brain or viscera. 

The physical signs are pathognomonic of this 
lesion provided compensation exists. The brunt 
of the burden is borne by the right auricle and 
ventricle which become hypertrophied. The left 
ventricle does not participate in the cardiac 
changes. 

Inspection. In children, rarely in adults, the 
hypertrophied right ventricle manifests its pres- 
ence by bulging of the lower sternum and fifth and 



ENDOCARDITIS AND CHRONIC VALVULAR DISEASE. 119 

sixth left costal cartilages. The apex beat is only 
slightly displaced. 

Palpation. As a rule a pronounced fremitus or 
thrill is felt in the fourth or fifth interspace within 
the nipple line. This thrill is characteristic and 
may be the only reliable sign of the lesion. The 
thrill is rough and grating, limited in area and 
culminates in a sharp sudden shock. The cardiac 
impulse is felt in the third and fourth interspaces 
and is due to an enlarged right ventricle. 

Percussion yields increased dullness to the right 
of the sternum and increased dullness upward as 
high as the second rib. 

Auscultation. In the mitral area, usually 
limited, a murmur of a churning and grinding 
character is heard which is synchronous with the 
thrill and terminates with a loud shock that is 
heard at the same time as the first sound. Like 
the thrill, this murmur is pathognomonic. This 
murmur is the presystolic murmur, occuping the 
entire period of diastole or more often the latter 
half of this phase. The second pulmonic sound is 
accentuated. The pulse is smaller in volume than 
normal, but regular. 

There are associated murmurs, chief of which is 
the mitral systolic, as stenosis rarely occurs without 
some incompetence of the valve. A tricuspid 
systolic murmur may be present owing to relative 
insufficiency of that valve. 



120 DISEASES OF THE HEART. 

tricuspid incompetency; tricuspid regurgi- 
tation. 

This rarely occurs as a result of valvular endo- 
carditis. As a rule, it is a relative insufficiency 
superinduced by dilatation of the right ventricle, 
secondary to lesions of the valves on the left side or 
pulmonary diseases, causing obstruction to the cir- 
culation. 

The symptoms are mainly revealed by physical 
signs and are made up of phenomena associated 
with obstruction in the pulmonary circulation and 
systemic veins. 

Diagnosis. 1. Pulsation of the veins of the 
necks, caused by systolic regurgitation of blood 
into the right auricle and the transmission of the 
pulse wave into the cervical veins. The right 
jugular vein pulsates more forcibly than the left. 
Kegurgitation into the vein is associated with the 
pulsation. To observe the phenomenon of regur- 
gitation, empty the external vein by pressing on 
the same just above the clavicle and moving it 
along the vein in the direction of the lower jaw. 
Thus emptied, with each cardiac systole, it will 
be observed to fill up from below. 

Eegurgitant pulsation may be transmitted to the 
inferior vena cava and thence to the hepatic veins, 
causing hepatic venous pulsation. Hepatic pul- 
sation is best felt by bimanual palpation, one hand 
over the fifth and sixth costal cartilages and the 



ENDOCARDITIS AND CHRONIC VALVULAR DISEASE. 121 

other over the liver in the axillary region. 2. 
A systolic murmur in the tricuspid area. It is 
usually soft, and blowing and may be absent. Per- 
cussion shows increased cardiac dullness to the 
right of the sternum. 

TRICUSPID STENOSIS. 

Very rare and usually fatal in origin. Other 
congenital lesions may mask its presence. The 
physical signs are those of mitral stenosis, with 
transference of the signs to the right side. Ex- 
treme cyanosis is common and dropsy extreme. A 
positive diagnosis is rarely made owing to its as- 
sociation with other lesions. 

PULMONARY VALVE LESIONS. 

Stenosis is one of the rarest of acquired lesions, 
but the most frequent of the congenital heart af- 
fections. The congenital lesion is associated 
usually with patency of the ductus Botalii and de- 
fect of the ventricular septum. Cyanosis and 
dyspnea are extreme. Auscultation shows a sys- 
tolic murmur in the second left interspace. 

Insufficiency. Like the foregoing it is usually 
congenital, but may arise from endocarditis or be 
merely relative from dilatation of the pulmonary 
artery at its origin. The murmur replaces the 
second pulmonic sound, and its intensity is in- 
creased during expiration. There is hypertrophy 
and dilatation of the right ventricle. 



1Z» DISEASES OF THE HEART. 

COMBINED VALVULAR LESIONS. 

In more than one-half of all the cases of cardiac 
valvular lesions, combined murmurs are present. 
Stenosis of a valve is, as a rule, combined with in- 
sufficiency of the same valve. Thus aortic stenosis 
and insufficiency coexist, but one may for a time 
compensate the other so that only the evidence of 
one lesion is demonstrable. Such a lesion as the 
one just cited would act as follows : The stenosis 
diminishes the regurgitated quantity of blood from 
the aorta into the left ventricle. Eelative insuf- 
ficiency of the mitral valve sequential to aortic 
insufficiency counteracts overfilling of the left 
ventricle and also over-distension of the aorta. 

A relative tricuspid insufficiency secondary to 
mitral disease may be doubly interpreted. Such a 
lesion may be speedily fatal owing to over-disten- 
sion of the general venous circulation, or it may 
prove salutary because it may relieve the right 
ventricle of its surplus of blood. The combined 
valvular lesions in order of frequency are: 1. 
Mitral and aortic segments. 2. Mitral and tri- 
cuspid lesions. 3. Aortic, mitral and tricuspid. 

Aortic insufficiency or aortic stenosis exists more 
frequently in combination with mitral insufficiency 
than aortic stenosis with mitral stenosis or mitral 
stenosis with aortic insufficiency. The most fre- 
quent association in adults is mitral insufficiency 
with slight aortic stenosis, whereas in children the 



ENDOCARDITIS AND CHRONIC VALVULAR DISEASE. 123 

most common association is aortic and mitral in- 
sufficiency. 

DIAGNOSIS. 

Valvular lesions are not difficult of location, 
even though several murmurs coexist, provided 
compensation is present. The average duration of 
compensation, based on a study of 102 cases by 
Romberg, has been found to be seven years. 
Sooner or later compensation fails and the heart 
becomes rapid and irregular with faint sounds and 
murmurs, a condition spoken of as delirium cordis. 
When this heart delirium occurs it is almost im- 
possible to correctly time the murmurs. Regula- 
tion of the cardiac action with digitalis and phy- 
sical rest may prove of advantage, but until some 
regulation is established it is often impossible to 
make a correct diagnosis. 

Differentiation of contemporaneous murmurs 
may be possible by percussion, auscultation and the 
inhibition maneuver. The secondary changes in 
the myocardium usually coincides with the pre- 
dominating murmur. If auscultation determines 
two murmurs of different character, one blowing 
and the other rough, two distinct murmurs exist. 
If again, we hear, let us say, a murmur at the apex 
and another at the aorta, auscultate step by step 
from one situation to the other. If it is every- 
where audible, but becomes louder toward one 



124 DISEASES OF THE HEART. 

point, then its origin is at the latter situation and 
is conveyed to the other. 

The inhibition maneuver described in the chap- 
ter on Diagnosis is an invaluable aid in causing 
transmitted murmurs to disappear to be replaced 
by tones. The maneuver should only oe attempted 
after forced expiration, for when the lungs are in- 
flated all endocardial murmurs are naturally 
weakened. 

CONGENITAL HEART DISEASE. 

The most frequent lesion is stenosis of the pul- 
monary orifice, associated very often with imper- 
fections of the ventricular septum and patency of 
the foramen ovale and ductus arteriosus. In 86 
per cent of patients with congenital heart disease 
living beyond the twelfth year, according to Pea- 
cock, the lesion is at the pulmonary orifice. 

Symptoms. Cyanosis is the chief symptom in 
over ninety per cent of the cases, hence the terms 
"blue disease" and "morbus ceruleus," which are 
other names for congenital heart disease. The 
lividity appears in the first week of life. The skin 
may be universally purple or may be confined to 
the fingers, lips, nose and ears. It is increased by 
exertion. Dyspnea and cough are common. Phy- 
sical development is retarded and the mind is 
sluggish. Clubbing of the fingers and toes is a 
common occurrence. 

Diagnosis. Cyanosis in children with or with- 



ENDOCARDITIS AND CHRONIC VALVULAR DISEASE. 125 

out enlargement of the heart, together with a mur- 
mur during the early weeks of life, is due to con- 
genital heart disease. 

Prognosis. More than one-half the patients die 
before the end of the first year, and not less than 
three-fourths before the end of the third year. 

MYOCARDITIS. 

Inflammation of the myocardium may be acute 
or chronic. Etiology. The acute specific fevers 
due to the infectious element. The chronic va- 
riety is associated with atheroma, and frequently 
complicates chronic Bright' s disease. 

The acute form may result in dilatation of the 
heart, fatty heart or aneurism of the heart. The 
chronic form may result similarly. 

Symptoms. The diagnosis, myocarditis is made 
more often by the pathologist than the clinician 
for the symptomatology of the disease is vague and 
uncertain. If in the course of an acute specific 
fever, precordial oppression, dyspnea and syncope 
occur and if to these symptoms, we add a rapid 
and weak pulse, signs of cardiac enfeeblement and 
the physical signs pertinent thereto, we may sus- 
pect myocarditis. 

The recognition of cardiac aneurism is made 
possible by careful percussion of the heart. The 
latter sign shows a projection beyond the line of 
cardiac dullness. With the Koentgen rays, I was 
able in one patient to trace with accuracy the ir- 



126 DISEASES OF THE HEART. 

regular outline of the heart and the diagnosis was 
confirmed at the necropsy, death having occurred 
suddenly after exertion from rupture of the heart, 
a frequent sequel in cardiac aneurysm. 

Treatment. Absolute physical rest and proper 
feeding are indicated. No drug beyond the use of 
strychnin is of advantage. Iodide of potash 
long continued is said to promote the nutrition of 
the heart. The Nauheim system of baths and re- 
sisted movements have given me marvelous re- 
sults in a few cases. In some instances the move- 
ments have been harmful. It is difficult to define 
indications for the baths and movements, the con- 
traindications are evidenced by the results of such 
treatment. 

PATTY HEART. 

Two pathologically distinct affections must be 
differentiated : 1, fatty degeneration in which the 
muscle fibers of the heart have been transformed 
into fat, and 2, fatty overgrowth in which the 
normal epicardial fat is increased in amount. 

FATTY DEGENERATION. 

Etiology. Nutritional disturbances of old age 
and the wasting diseases. Infectious fevers, 
chronic anemia, arsenical and phosphorus poison- 
ing, diseases of the coronary arteries and finally 
as a secondary lesion in cardiac hypertrophy. 

Symptoms. Diagnosis is, as a rule, obscure. 
The chief sign is cardiac enfeeblement. Cardiac 



ENDOCARDITIS AND CHRONIC VALVULAR DISEASE. 127 

asthma, angina pectoris, pseudo-apoplectic at- 
tacks and pulse retardation (30-40 beats per min- 
ute) are relatively frequent. Cheyne- Stokes 
breathing and the fatty arcus senilis, formerly re- 
garded as pathognomonic, are untrustworthy. 

FATTY OVERGROWTH. 

An increase of subpericardial fat is usually a 
manifestation of general obesity. The recognition 
of the condition is based on the general obesity 
associated with signs of heart failure, viz. : Asthma, 
syncopal attacks, bronchitis with weak and muffled 
heart sounds. Sudden death occurs from syncope 
or from rupture of the heart. 

Treatment. The treatment of fatty degenera- 
tion is strictly symptomatic. Fatty overgrowth 
is greatly benefited by the method of Oertel re- 
ferred to under general treatment as well as by 
the Schott method. 



CHAPTER VI. 

NEUROSES OF THE HEART. 

The rapidity and force of cardiac action are 
regulated by the pneumogastric or vagus nerve 
which inhibits it and the sympathetic which ac- 
celerates it. In the heart the blood pressure is 
regulated by a branch of the vagus, the depressor 
nerve, which acts by causing sudden dilatation of 
the large abdominal vessels to lessen cardiac pres- 
sure or by constricting them to raise it. The vaso 
motor system of nerves regulates the caliber and 
tone of the blood vessels. It is connected with the 
heart, so that tension of the arteries and force of 
the cardiac pulsations are regulated with each 
other. 

The coronary arteries are the nutrient vessels 
of the heart. They arise from the aorta imme- 
diately behind the valve and their blood is re- 
turned by a vein to the right auricle, where its 
opening is guarded by a little valve. 

GENERAL ETIOLOGY. 

Largely reflex from the stomach and intestines. 
Peripheral irritation of the gastric branches of the 
vagus by the products of indigestion is a fruitful 
cause. How this irritation is induced is as yet 



NEUROSES OF THE HEART. 



a conjectural matter, although we do know that 
when treatment is directed toward the relief of a 
gastric affection cure is often attained. 

The absorption of substances from the intestinal 
tract which are the result of bacterial activity, 
must also be taken into consideration, and while 
we possess no means of demonstrating such prod- 
ucts in the circulation we assume that they exist 
owing to the good results following treatment. 
Cleansing the intestinal tract is often a herculean 
undertaking, but like the fabled stables of Augeas 
our endeavors must be more in the direction of 
asepsis than antisepsis. 

The genito-urinary apparatus of both sexes is 
frequently implicated in the etiology of cardiac 
neuroses and demand careful investigation. A 
similar statement is apposite with reference to 
the naso-pharynx. Anemia is a common cause 
and so is the inordinate use of alcohol, tea, cof- 
fee and tobacco. Mental excitement, depression 
or emotion is a causative factor. 

In a number of individuals no etiologic factor 
beyond a neurasthenic condition may be demon- 
strated, and it would appear in these cases as if 
the cardiac apparatus bore the brunt of the in- 
sanity of the nervous system representing, as it 
were, the locus minoris resistentiae. At any rate 
I have known the most intractable cardiac neu- 
roses yield to a thorough rest cure. 



130 DISEASES OF THE HEART. 

I. Palpitation. 
This term is applied to conscious cardiac con- 
tractions of the heart of increased force asso- 
ciated with a disturbance of rlrythm and sometimes 
with distress in the precordia, dyspnea and anxie- 
ty. Besides the factors previously mentioned in 
the general etiology, the nervous phenomenon may 
be associated with organic heart disease, although 
this is infrequent. The irritable heart described 
by Da Costa, common among the young soldiers 
during the Civil war, is a similar neurosis. Two 
facts were concerned in its causation, mental ex- 
citement and excessive muscular exertion. 

DIAGNOSIS. 

Visible cardiac pulsations against the chest wall, 
pulse 120-160 per minute and loud cardiac tones 
are practically the objective symptoms of a par- 
oxysm which may last from a minute to an entire 
day. A mild paroxysm, often the result of indi- 
gestion, is attended by a slight fluttering of the 
heart and a sensation which the patient describes 
as a "goneness." The diagnosis of nervous palpi- 
tation should only be made when careful exami- 
nation of the heart reveals no evidence of organic 
disease. A murmur must not be construed as evi- 
dence, insomuch as it is often hemic, and anemia 
is largely concerned in the causation of the neu- 
rosis. 



NEUROSES OF THE HEART. 131 

TREATMENT. 

Suggestion plays an important role. Convince 
the patient that the trouble is purely functional 
and half the battle is won. To logically carry out 
this suggestion medicines are contra-indicated ; as 
much may be effected by hygienic measures. Keg- 
ulating the methods of living, careful dieting, 
avoidance of alcohol, coffee, tea and tobacco, in- 
terdicting sexual excitement and mental excite- 
ment, bowel regulation and a modified rest cure 
are a few hygienic regulations. 

The paroxysm of palpitation may be arrested 
by certain mechanic manipulations, especially in 
hysterical persons, by pressure on the vagus in the 
neck and certain hysterogenic zones on the abdo- 
men, particularly the ovarian region. Eest in bed 
and an ice bladder to the precordia may also be 
tried. The bromides, valerian, camphor and hyos- 
cyamus may prove beneficial, but the most effect- 
ive remedy is unquestionably morphin when given 
hypodermically. Eecurrent paroxysms may be 
prevented by observing indications for therapeutic 
measures, the treatment of anemia, hysteria, ma- 
laria, gout and the uric acid diathesis. Galvanism 
of the vagus is sometimes beneficial. The con- 
tinued use of tincture of nux vomica in large doses 
is particularly valuable. One of my patients, a 
physician, suffering from palpitation for ten years, 
found almost immediate and permanent relief 



182 DISEASES OF THE HEART. 

from the Schott methods of resistance exercises 
and baths. 

II. Paeoxysmal Tachycaedia (Rapid Heaet). 

This is a paroxysmal affection variable in dura- 
tion, associated with a feeling of great anxiety, in 
which the number of pulse beats may reach 150 
or more. Two forms have been described, neurotic 
and symptomatic tachycardia. The causes of the 
former variety are the same as in palpitation. The 
symptomatic variety may be due to central and 
peripheral causes. 

Central causes : lesions of the brain and cord. 

Peripheral causes : tumors, aneurisms, enlarged 
lymph glands which compress the vagus and neu- 
ritis of the vagus. 

The rapid heart is directly dependent upon eith- 
er paralysis of the vagus or stimulation of the 
sympathetic nerves. Fraentzel suggested that the 
cause could be ascertained by digitalis and mor- 
phin. If the vagus were at fault the former drug 
would prove effective, whereas if the sympathetic 
were at fault morphin would prove useful. 

DIAGNOSIS. 

Heart hurry is characterized by paroxysms of a 
high pulse rate (in one of my patients 300 beats 
per minute) without a palpable cause, dissociated 
with any cardiac anomaly in the inter-paroxysmal 
periods. Nothnagel decides that a great increase 



NEUROSES OF THE HEART. 133 

in the pulse frequency, accompanied by a weak 
heart beat, speaks for paralysis of the vagus, 
whereas a strong impulse, fullness of the periph- 
eral arteries with high tension is in favor of 
stimulation of the accelerators. This condition 
must not be confounded with a normally rapid 
pulse nor with an increased pulse rate occurring 
in certain pathologic conditions. 

TREATMENT. 

The same general methods recommended in the 
treatment of palpitation are here applicable. 
Digitalis has been serviceable, but no dependence 
can be placed on its action. Subjugation of the 
paroxysm of tachycardia may be accomplished by 
galvanization of the vagus (positive pole under 
angle of jaw, negative pole lower down over each 
side of neck). In a case reported by Nothnageh 
attacks were jugulated by deep inspirations. 
Eosenfeld's patient controlled her attack by going 
to bed, raising her head with her feet planted 
firmly against the foot of the couch, and then 
taking a forced inspiration she pressed down with 
all her might, with the object of closing the glottis. 
Schott warmly recommends his balneologic and 
gymnastic methods. The long-continued use of 
iodide of potash proved curative in one of my 
patients. A colleague controlled his attacks with 
digitalis. He had tried twelve preparations of 



134 DISEASES OF THE HEART. 

the tincture from as many different drug stores 
without any result. A thirteenth preparation 
from an homeopathic pharmacy was succcessful. 

III. Brachycardia (Bradycardia — Slow 
Heart). 

Slowness of the pulse may be physiologic. Na- 
poleon had a pulse of only 40 per minute. Before 
deciding whether brachycardia really exists it is 
necessary to determine if the arterial and heart- 
beats correspond, for while the cardiac pulsations 
may be 70 only 30 beats reach the radial pulse, 
therefore the cardiac contractions and not the 
pulse beats should be counted. KiegeFs classifi- 
cation of brachycardia is the one usually accepted. 

Physiologic brachycardia. — In the puerperal 
state a slow pulse is a common manifestation when 
it may reach a rate as low as 34. 

Pathologic brachycardia is present in conva- 
lescence from acute fevers, notably rheumatism, 
diphtheria, pneumonia and typhoid fever. The 
cause is most probably resident in the heart muscle 
and not dependent on exhaustion as maintained by 
Traube. 

Diseases of the digestive organs was the chief 
etiologic factor in Eiegel's cases. Diseases of the 
lungs. — In valvular heart lesions it is not com- 
mon, although in degeneration of the heart muscle 
it is frequent. Cases of fatty heart have been ob- 



NEUROSES OF THE HEART. 135 

served where the pulse rate was only 12 per min- 
ute, and this rate was maintained for years. Ne- 
phritis, toxic agents, diabetes, anemia, diseases of 
the cord and brain are regarded as other causes. 
Brachycardia arising reflexly from some dis- 
turbance in the gastro-enteric tract is easily under- 
stood when we remember how readily the inhib- 
itory action of the vagus may be excited through 
this channel. In diseases of the heart, brain and 
kidneys it is often an ominous sign. It is often a 
symptom in uremia. Muscarin and the biliary 
salts can produce a slow pulse. Eapid resorption 
of large quantities of bile not only slows the pulse 
but makes the heart action irregular. Thus, in 
catarrhal icterus a slow pulse is a common occur- 
rence. 

SYMPTOMS. 

During a paroxysm. Syncopal attacks occur and 
the patient may remain unconscious for hours. 
During the attack the heart impulse and sounds 
are feeble. Sudden death may terminate an at- 
tack. 

TREATMENT. 

Eest is essential. The treatment is mainly 
symptomatic, although a thorough examination 
may often determine a causal condition, the re- 
moval of which cures the affection. To excite the 
action of the heart in a paroxysm, caffein, strych- 
nin and nitro-glycerin may successively be tried. 



136 DISEASES OF THE HEART. 

IV. Arrhythmia (Irregular Heart). 
An irregular heart may be clinically manifested 
as an intermission when one or more beats of the 
heart are dropped, or as an irregularity when the 
beats show inequality in volume and force. Ar- 
rythmical action is expressed by the following well 
recognized varieties of pulse : 

1. The paradoxical pulse, in which during in- 
spiration the beats are more rapid though less full 
than in expiration. It attends chronic adhesive 
pericarditis when fibrous bands become attached 
to the root of the aorta. It may be felt in the 
sleeping child. 

2. Intermittent pulse signifies a missed or 
dropped beat. This intermittency may be irreg- 
ular or cyclic, an intermittence occurring at every 
fourth, sixth or eighth beat. 

3. The alternate pulse is expressed by alternate 
full and feeble pulse beats. 

4. The bigeminal pulse occurs when two beats 
follow each other quickly and the next two not so 
quickly, three such beats occurring in rapid suc- 
cession gives rise to the trigeminal pulse. 

5. The pulse of delirium cordis gives rise to 
marked irregularity and inequality of the pulse 
beats. 

Irregularity of heart rhythm may give no 
expression in the pulse. We have embryocardia 
or fetal heart rhythm in which shortening of the 



NEUROSES OF THE HEART. 137 

long pause exists, and the first and second sounds 
as in the fetal heart are similar. This sign is of" 
ominous import in fevers, indicating a weak heart. 
Gallop or cantering rhythm, expressed by the words 
"rat ta-tat," are sounds simulating the triple foot- 
fall of a horse at canter. Present in arterio- 
sclerosis, interstitial nephritis and myocarditis. 
It may be met with in health. 

ETIOLOGY. 

The causal classification of Baumgarten is usu- 
ally accepted: 1. Organic cerebral affections. 2. 
Keflex from diseases of the viscera. 3. Toxic; 
tobacco, coffee, tea and from such drugs as digi- 
talis, belladonna and aconite. 4. Changes in the 
heart. 

SIGNIFICANCE. 

Arrhythmia may exist for a long period without 
symptoms. It is usually in association with other 
cardiac signs that its presence is noted. Asso- 
ciated with myocardial or valvular lesions it is 
ominous, but as a permanent condition secondary 
to mental influences it is usually without signifi- 
cance. The treatment is symptomatic. 
Angina Pectoris (Stenocardia — Breast Pang, 

Cardiodynia). 
A symptomatic paroxysmal affection (described 
by Heberden as the breast pang) associated with 
cardiac lesions. 



138 



DISEASES OF THE HEART. 



ETIOLOGY AND PATHOLOGY. 

An affection of adult life occurring chiefly in 
men. Associated, as a rule, with arterio-sclerosis, 
hypertrophy of the heart and lesions of the myo- 
cardium and aorta. No hypotheses yet advanced 
suffice to account for its symptomatology. The 
hypotheses thus far advanced are : 1. That it is 
a neuralgia of the cardiac nerves. 2. A cramp of 
the heart muscle (Heberden). 3. Extreme ten- 
sion of the ventricular walls following acute dila- 
tation with involvement of the coronary arteries 
(Traube). 4. Spasm of the coronary arteries with 
increased intra-cardiac pressure. In fatal cases 
the coronary arteries are usually diseased. In one 
of my patients the coronary arteries were practi- 
cally calcareous tubes, yet the pulse showed no evi- 
dence of arterio-sclerosis with the sphygmograph. 

SYMPTOMS. 

The paroxysm begins suddenly, usually after 
some exciting cause. There is agonizing pain in 
the heart region, radiating up the neck and down 
the arms, particularly to the left arm. The sen- 
sation is one of impending death and the feeling 
one as if the heart were held in a vise. The face 
is pale and bathed in perspiration. Dyspnea is not 
the rule. Little or no changes are noted in the 
pulse or heart during an attack. The paroxysm 
is of short duration (few seconds to three min- 



NEUROSES OF THE HEART. 139 

utes) and is followed by eructations of gas, vom- 
iting or discharge of a large quantity of clear 
urine. The attacks may recur at intervals of from 
weeks to years. The chief diagnostic points are: 
1. Sudden intense pain and sense of impending 
death. 2. Occurrence in men between the ages of 
40 and 60. 3. Existence of arterio-sclerosis char- 
acterized by accentuated second aortic tones and 
pulse of high tension. I can recall two individ- 
uals who for years suffered from slight pains in 
the left arm with numbness in the hand and fin- 
gers who eventually died in a typical attack of 
angina. 

A variety of the true form of angina has been 
described by Nothnagel as angina vasomotoria. 
This form follows exposure to cold and is charac- 
terized by a general spasm of the peripheral ar- 
teries with pallor of the face and coldness and 
stiffness of the limbs. The chief difficulty in diag- 
nosis is to differentiate the true from the false or 
hysterical pseudo-angina. The chief diagnostic 
signs of pseudo-angina are : 1. Occurrence in 
hysterical women and nearasthenic men. 2. Oc- 
currence at every age. 3. Attacks are periodical, 
spontaneous and often nocturnal and associated 
with nervous symptoms. 4. Attack lasts from a 
half to several hours, and is never fatal. 5. Asso- 
ciated with extreme restlessness and emotional 
symptoms. 



140 DISEASES OF THE HEART. 

I am surprised to find in the literature very 
little reference to a dilated stomach as the cause 
of pseudo-angina, a form described by myself as 
gastrectatic pseudo-angina. I have frequently en- 
countered this affection and permanent cures have 
followed treatment directed toward the stomach by 




Fig. ii — Dull area in dislocation of heart upward by 
a dilated stomach. 

a suitable dietary and lavage. If the gastric 

trouble is provoked by neurasthenia, the latter 

condition demands treatment. 

In a previous chapter I have demonstrated the 

facility with which a dilated stomach may dislo- 



NEUROSES OF THE HEART. 141 

cate the heart, since which time I have discovered 
a new and trustworthy sign of heart dislocation 
consecutive to gastrectasis. It is a circumscribed 
area of dullness, often amounting to flatness in the 
left interscapular region between the internal bor- 
der of the scapula and spine. Over the dullness 




Fig. 12 — Same case. Area of dullness increased by 
patient leaning backward. 

bronchial respiration is heard. When the patient 

is directed to lean forward the dullness disappears 

and likewise the bronchial breathing, but are again 

in evidence when the erect attitude is resumed. 

When the patient is directed to lean backward the 

area of dullness is very much increased. 



142 DISEASES OF THE HEART 

This phenomenon is caused by a dislocated heart 
compressing the lung, which fact is easily demon- 
strated by examination with the Koentgen rays. 
The foregoing syndrome I have reproduced syn- 
thetically by distending the stomach with air, thus 
proving the correctness of my conclusions. Iden- 
tical percussional phenomena may be observed 
when the heart is enormously enlarged upwards. 

The prognosis is always bad in true angina, al- 
though years may elapse before a fatal termina- 
tion, provided excitement, muscular exertion and 
dietetic errors are avoided. Vasomotor angina is 
less grave and pseudo-angina is always favorable. 
Cardiac pain without evidence of arterio-sclerosis, 
or valve disease, is not of much moment (Osier). 

TREATMENT. 

A quiet life should be encouraged. Attacks may 
be curtailed and prevented by inhalations of ni- 
trite of amyl, perles of which containing 3 to 5 
drops should be constantly carried by individuals 
thus afflicted. If the attack is not controlled one 
minim of the 1 per cent solution of nitro glycerin 
should be given hypodermically and repeated every 
15 minutes if pain continues, or until the physio- 
logic effects (flushing of the face and headache) 
are evident. When this fails chlorof orm by inhala- 
tion or a hypodermic of morphia may be given. 
In the intervals between the attacks the prolonged 
use of the iodide of potash in 20-grain doses three 



NEUROSES OE THE HEART. 143 

times a day may control the frequency of the at- 
tacks by influencing the associated arterio-selerosis, 
especially if there is a history of syphilis. 

Habitual exaltation of arterial tension is influ- 
enced by increasing doses of nitro-glycerin until a 
dose large enough to produce its physiologic action 
is attained. Sodium nitrite (dose gr. i-iii) has a 
similar action. In pseudo-angina the causal con- 
dition must be eliminated. Static electricity has a 
marked psychic action in cases of pseudo-angina. 
The Schott system of baths and exercises improve 
the condition of the heart, muscle and arteries and 
should be employed in the true forms of angina. 
Erythrol-tetranitrate in grain doses, four times 
in the 24 hours, is a new remedy for the relief 
of the anginal attacks. 



CHAPTER VII. 

AFFECTIONS OF THE ARTERIES. 

Arterial Sclerosis — Arterio-Sclerosis; Ar- 
terio-capillary fibrosis; atheroma. 

pathology and etiology. 
The normal activity of an organ is dependent on 
the integrity of its blood-vessels. The span of 
life is determined by the so-called vital rubber of 
the arterial tissue, and justifies the oft quoted 
axiom, "A man is only as old as his arteries." Not 
long ago I examined a youth of ten who was prac- 
tically an old man with his rigid and incom- 
pressible radials. The pathologic process of 
arterio-sclerosis is essentially a chronic process 
leading to an increase of arterial connective tissue 
involving primarily the internal coat (intima) fol- 
lowed by calcareous infiltration. Sclerosis of the 
veins (phlebo-sclerosis) may be primary or second- 
ary to the same changes in the arteries. Arterio- 
sclerosis is often an hereditary affection aided by 
factors which result in the misuse of arteries. 
Among the common causes are: 1. Chronic intox- 
ications: lead poisoning, syphilis, alcoholism, uric 
acid, etc., which by augmenting the resistance in 
the peripheral vessels, raise the arterial pressure. 



AFFECTIONS OF THE ARTERIES. 145 

2. Overeating is regarded as a frequent cause, the 
excess of food and fluid ingested fill the blood 
vessels to repletion. 3. Inordinate muscular work 
leads to peripheral resistance with consequent rise 
of blood pressure. 4. Bright's disease may lead 
to primary or secondary arterial degeneration. The 
causal factors predominating in males, it is but 
natural that the latter are the chief victims to 
the affection. 

SYMPTOMS. 

An acute arteritis is almost never of clinical 
interest although some clinicians claim to make a 
diagnosis of acute aotitis by the fixed retro-sternal 
pain associated with acute disease of the aortic 
valves. Arterio-sclerosis is frequently a post- 
mortem discovery. The diagnosis rests on the 
general manifestations, but more often on symp- 
toms referred to special organs, the arteries of 
which are particularly implicated in the sclerotic 
process. The accessible blood-vessels are hard and 
incompressible. The sensation is often that per- 
ceived in grasping a goose's neck. The pulse can- 
not be obliterated. The pulse may be of high 
tension yet no sclerosis exists. If there is any 
doubt, palpate the pulse with two fingers. If the 
artery is felt beyond the point of compression and 
is easily distinguished from the other tissues, its 
walls are sclerosed. 

Next to increased arterial tension, hypertrophy 



146 DISEASES OF THE HEART, 

of the left ventricle is the most frequent symptom. 
Increased arterial tension, palpable arterial in- 
duration and hypertrophy of the left ventricle are 
pathognomonic of the disease. There are distinct 
types of arterio-sclerosis: 1, cardiac; 2, cerebral; 
3, renal; and 4, peripheral types. 

Cardiac sclerosis of the coronary arteries may 
be associated with varied myocardial lesions, not- 
ably: fibroid degeneration, angina pectoris, heart 
aneurism, etc. The hypertrophied heart so com- 
mon in arterio-sclerosis may eventuate in dilata- 
tion followed by the usual signs of cardiac in- 
sufficiency (dyspnea, dropsy, etc.) 

Cerebral. The milder symptoms are vertigo, 
cephalalgia, tinnitus, syncopal attacks and tran- 
sient aphasia and paralysis. Thrombosis, cerebral 
embolism and the formation of miliary aneurisms 
followed by rupture are associated lesions. 

Eenal. The symptoms are practically those of 
contracted kidney, viz.: polyuria, uremic headaches 
and vomiting. In the peripheral type, tissue star- 
vation leading to gangrene may ensue. Implica- 
tion of the peripheral arteries in the scelrotic pro- 
cess does not necessarily imply that the aorta and 
its branches are seriously involved. 

Eecognition of increased arterial tension is often 
a matter of education. The tonometer of Gaertner 
is an instrument of precision in gauging blood- 
pressure. The blood-pressure in healthy young 



Affections of the arteries. 



147 



persons is from 100-130 millimeters of mercury. 
With the tonometer, one may recognize arterio- 




Fig. 13. 

a — Tonometer provided with a mercurial gauge, 
b — Same instrument more portable, provided with 
a metal gauge. 

sclerosis without palpable changes in the periph- 
eral vessels. When the tonometric figures are 



148 DISEASES OF THE HEART. 

low with clinical evidence of arterio-sclerosis, it 
is a sign of failing heart power. 

Anyone mechanically inclined can easily con- 
struct a tonometer at small expense. The one I 
have used for some time, I am indebted for to Dr. 
A. W. Perry of San Francisco, who made several 
for his medical friends. 

TREATMENT. 

The causal factors must be considered. A his- 
tory of syphilis suggests the iodides, which may 
generally be recommended as routine treatment. 
For the high pulse tension, nitro-glycerin. Vene- 
section is indicated in instances of very high ten- 
sion associated with plethoric symptoms. Use may 
also be made of the Schott methods. 

Aneurism of the Thoracic Aorta, 
etiology and pathology. 
The etiology is concerned with the same factors 
predominant in arterio-sclerosis. Alcohol, syphilis 
and overwork, single and in combination, furnish 
the impetus for aTterial changes conducive to 
aneurism. The different varieties of aneurism are 
of greater interest to the pathologist than the 
clinician. The thoracic portion of the aorta, ac- 
cording to Lyman, is implicated in 75 per cent 
of the cases of aneurism. Within the chest nearly 
60 per cent of the cases originate in the ascending 



AFFECTIONS OF THE ARTERIES. 149 

portion of the aorta, while nearly 30 per cent are 
seated upon the arch of the vessel. 

SYMPTOMS. 

Bramwell's clinical division of aneurism is a 
practical one: 1. Latent aneurisms which give no 
physical signs. 2. Those presenting signs of intra- 
thoracic pressure but in which it is difficult or im- 
possible to determine the nature of the lesion pro- 
ducing the pressure. 3. Aneurisms with marked 
pressure symptoms and external signs. Our pri- 
mary object is to make the diagnosis of thoracic 
aneurism and later to define its site. The former 
object is attained by the recognition of pressure 
symptoms and objective signs. 

PRESSURE SIGNS. 

Pain is an important and almost constant sign. 
When dependent on pressure or stretching of the 
nerves, it is sharp and lancinating and may be 
paroxysmal owing to alterations in the intra- 
aneurismal pressure. When due to pressure against 
the bony structures, it is a continuous gnawing or 
boring pain. 

Cough. Usually paroxysmal. When due to 
pressure on the recurrent laryngeal nerves it is of 
a brazen ringing character. Pressure on the 
trachea or bronchus may also provoke a cough. 

Dyspnea owes its origin to one of the following 
causes: 1, Tracheal compression; 2, compression 



150 DISEASES OF THE HEART. 

of the left bronchus; 3, pressure on the recurrent 
laryngeal nerves. 

Venous enlargement of the veins of the head and 
arm occurs when the vena cava is compressed. 

Edema of the right arm occurs when the sub- 
clavian vein is compressed. Localized edema of 
the chest may be present. 

Aphonia and dyspnea occur when the right 
laryngeal nerve is involved. Pressure of the left 
recurrent laryngeal causes paralysis of the cor- 
responding cord with aphonia. Pressure on the 
sympathetic nerve causes pupillary contraction; on 
the thoracic duct, wasting, on the esophagus, dys- 
phagia, on the left bronchus, bronchiectasis with 
bronchorrhea. 

PHYSICAL SIGNS. 

Inspection. With an abnormal pulsation, a tu- 
mor may be visible. The apex beat is displaced 
from pressure. 

Palpation. In deep-seated aneurisms, pulsation 
is best detected by bimanual palpation, one hand 
over the spine and the other on the sternum, at 
the same time exerting pressure with the hand 
on the sternum. In addition to the pulsation one 
may feel the diastolic shock, a valuable sign. 

Percussion yields the most reliable evidence. 
Dullness amounting to flatness can be obtained 
over a superficial aneurism, the area of dullness de- 
pending of course on the situation of the sac. 



AFFECTIONS OF THE ARTERIES. 151 

Auscultation. A murmur if present is systolic 
in time with maximum intensity over the area of 
dullness and, transmitted in the direction of the 
cervical vessels and along the course of the aorta; 
a coexistent diastolic murmur is usually associated 
with aortic insufficiency. 

In the peripheral arteries the volume of the 
pulse is lessened. The pulse in the two radials 
may show differences in volume and time. 

Among the recent signs are the following: 1. 
Tracheal tugging. The patient's head being in- 
clined forward to relax the neck and the cricoid 
cartilage is grasped between the thumb and index 
finger, the trachea at the same time drawn upward, 
when, if aneurism is present, a pronounced ascend- 
ing motion will be felt at each pulsation. During 
the maneuver, breathing must be suspended and 
care must be observed to avoid mistaking the trans- 
mitted pulsations in the cervical vessels. Ewart 
modifies this method with advantage. The ob- 
server stands behind the patient steadying the 
latter's head against his body and grasping the 
cricoid cartilage as before. In health, the symp- 
tom is only slightly present if at all. 2. Oblitera- 
tion of the pulse in the abdominal aorta and its 
branches. When this sign is present, the aneur- 
ismal sac acts as a reservoir annihilating the ven- 
tricular systole and converting the intermittent 
into a continuous stream (Osier). 3. Systolic mur- 



152 DISEASES OF THE HEART. 

mur heard in the trachea or at the patient's mouth 
when opened (Drummond). 4. Tying the ex- 
tremities or compressing the f emorals and axillary- 
arteries will intensify the pressure symptoms. 5. 
Intra-thoracic auscultation. An esophageal tube 
with a large aperture at the end is introduced into 
the esophagus and connected with a stethoscope. 
Aneurismal pulsation and murmur are heard 
(Eichardson). 6. Systolic pulsations in the larynx 
and trachea are heard (Oliver). 7. The X-rays 
furnish trustworthy evidence. I have frequently 
detected thoracic aneurisms by their aid when no 
sign was present. Of course errors are as frequent 
by this as by other methods, but a thorough mas- 
tery of chest radioscopy is the only reliable means 
of eliminating mistakes. 

LOCATING THE SITE OF AN ANEUEISM. 

Ascending aorta. Pressure symptoms evident by 
distension of the veins of the neck, head and arms. 
Displacement of the heart outward, forward and 
upward. Appearance of tumor and dullness to 
the right of the sternum in the upper second or 
third intercostal spaces. 

Transverse portion. Intense pressure symptoms 
owing to the relatively shorter antero-posterior 
diameter of the chest at this point. The tumor 
may appear in the jugular fossa. Area of dullness 
over the manubrium or along the left sternal bor- 
der. 



AFFECTIONS OF THE ARTERIES. 153 

Descending portion. Pressure signs are slight. 
Evidence of vertebral compression with intense 
pain. Dullness, if present, appears at a point on 
the left side of the spine at about the eighth dorsal 
vertebra. 

Prognosis. Usually fatal. Spontaneous cure, 
rare. Death from pressure symptoms or rupture. 

DIAGNOSIS. 

From pulsation of the aorta seen in aortic re- 
gurgitation; often difficult. In such instances 
defer diagnosis until tumor is unmistakable. 
Aortic pulsations in neurotic subjects: Negative 
signs of aneurism. Pulsating empyema: In this 
affection, throbbing is diffuse, moving the entire 
side; pulsation not expansile; absence of mur- 
mur and diastolic shock; hypodermic needle 
shows pus. Solid tumors: Pressure phenomena 
less marked; if tumor shows pulsation it is not 
expansile nor attended by the auscultatory signs 
of aneurism; tracheal tugging is absent. 

TREATMENT. 

Rest and a restricted diet. A low diet such as 
suggested by Tufnell reduces intra-aneurismal 
pressure and favors coagulation. Potassium iodide 
(10 to 20 grains, 3 times a day) is of undoubted 
value. Venesection often gives relief to pressure 
symptoms. Insertion of wire into the sac with 
the use of electrolysis according to the Loreta 
method has given me good results in two cases. 



154 DISEASES OF THE HEART. 

My colleagues Kerr and Eosenstirn of this city 
have also reported cures. Thorne and others have 
reported much improvement following the use of 
baths on the Schott principle. 

A method of recent introduction and worthy of 
some consideration is the use of gelatin injections. 
In 1895, Dastre demonstrated that if a solution 
of gelatin is injected into the veins of a dog, it 
made the blood more coagulable. The solution 
for injection consists of a 1 per cent sterilized 
solution of gelatin in a 0.1 per cent solution of 
sodium chloride. Of this solution, from 2-5 ounces 
is injected every third or fifth day, according to 
the reaction, into the sub-cutaneous tissues. No 
danger attends this treatment beyond the possi- 
bility that a clot may be carried into the general 
circulation. The solution for injection is placed 
in a flask, which is sealed and then sterilized. 
When ready some of the solution is introduced into 
a flask fitted with a cork and two tubes like a wash- 
bottle. To the long tube a sterilized needle is 
attached and to the short tube, a rubber air ball. 
The flask is introduced into a water bath to liquefy 
the gelatin and while kept there, the injection is 
begun. 

The calcium salts have recently been recom- 
mended. Marked improvement in one of Cohen's 
cases followed the use of hydrated calcium chloride 
in doses of 1 dram daily. 



CHAPTER VIII. 

ADDENDUM. 

The Heart Eeflex. 

Three years ago attention was directed to an 
heretofore undescribed clinical phenomenon which 
I called the heart reflex. It is practically a myocar- 
dial contraction consequent on irritation of the 
skin of the precordia by vigorous rubbing with 
the finger or better still by a spray of ether and 
is manifest by the Roentgen rays and the fluoro- 
scopy It can be most easily provoked in children. 
The contraction of the myocardium is of sudden 
and momentary duration and, like other reflex acts, 
soon becomes exhausted. My assistant, Dr. Louis 
Gross, and myself saw both ventricles recede fully 
1^ inches on either side after directing a spray of 
ether on the precordia in an emaciated girl of 14 
years. Of course the anatomic heart in the adult 
measures only 3^ inches in breadth, but we are 
here concerned with the physiologic heart. 

To properly appreciate the phenomenon of the 
heart reflex for therapeutic and diagnostic pur- 
poses, attention must be directed to the lung re- 
flex.* If the skin of the thorax is irritated, arti- 



*New York Medical Journal, Jan. 13, igoo, 



156 DISEASES OF THE HEART. 

ficial lung dilatation ensues. The degree of dila- 
tation varies with the severity and extent of cu- 
taneous irritation. Vigorous rubbing of the skin 
of the precordia is sufficient to obliterate the area 
of superficial cardiac dullness, if irritation is made 
over the lower lung border, percussion will show in 
the axillary line a descent of the lower lung border 
fully 6 cm., a degree of dislocation even exceeding 
that obtained by forced inspiration. Aside from 
its percussional recognition, the appearance of 
the reflex by means of the Koentgen rays is dis- 
tinctive. Coincident with the discharge of the 
reflex, the lung area implicated shows increased 
brightness lasting from a few seconds to four min- 
utes, the lung after that time assuming the normal 
skiascopic appearance. 

In a recent contribution,* I espoused the theory 
that the real factor involved in balneo- and 
mechano-therapeutics (Schott treatment) was de- 
pendent on cutaneous irritation provoked by exer- 
cise and baths. In accordance with this theory, I 
have since this contribution employed vigorous 
cutaneous friction by means of a rough towel after 
immersion of the patients in a warm bath (15 min- 
utes duration) in cases of chronic heart disease 
with results emulating the conventional Schott 
method. By my simple and expeditious method, 
relief of dyspnea follows, there is reduction in 

*The Medical News, Jan. 7, 1899. 



ADDENDUM. 



157 



cardiac volume and a marked reduction in pulse 
rate with increase in volume and force. The ac- 
companying illustration is a rough reproduction 
obtained in a young man with a massive dilatation 
of both ventricles; a, represents the percussional 
area of the heart. The dark area represents the 




Fig. 14— Illustration of Heart Reflex. 

a — Percussional area of dilated heart. 

b — Area after application of cutaneous irritation. 

area of cardiac dullness after directing a spray of 
ether on the skin of the precordia and is caused 
not wholly by a reduction in cardiac volume but 
by the lung reflex which induces the dilated lung 
to encroach on the area of cardiac dullness. After 



158 DISEASES OF THE HEART. 

waiting ten minutes, a time exceeding that neces- 
sary for the lung to recede, the percussion area, b, 
is obtained, which actually represents the decrease 
in the area of the heart. Like results follow treat- 
ment by cutaneous irritation. 

This illustration will serve to exemplify the aid 
which this phenomenon furnishes in the differen- 
tial diagnosis of a pericardial exudate from a dila- 
tation of the heart, and I regard this heart reflex 
test as pathognomonic and far exceeding all other 
methods yet recommended in differentiation. One 
of the most difficult problems for the clinician is to 
distinguish between a dilatation of the heart and 
pericardial effusion. If in a given case of increased 
cardiac dullness which has been carefully outlined, 
we direct a spray of ether on the skin of the pre- 
cordia and note after four minutes (the time nec- 
essary for the lung reflex to be abolished) a reduc- 
tion in the area of cardiac dullness however slight, 
we are justified in concluding that we are dealing 
with cardiac dilatation and not with a pericardial 
effusion. The heart reflex is also a valuable index 
to the state of the myocardium. 

Eelation of Diseases of the Heaet to Other 
Diseases. 
Abdominal Typhus. — Myocarditis is often re- 
sponsible for sudden circulatory collapse. Pulse 
rate not in proportion to temperature. Average 



ADDENDUM. 159 

rate, 84-110 per minute. Pulse of more than 
130 for some days is an ominous sign. Pulse 
clicrotism, characteristic but not pathognomonic. 
During convalescence a sub-normal pulse rate is 
frequent. Venous thrombosis occurs in one per 
cent of all cases (Murchison). It is the result 
of cardiac failure and implicates most frequently 
the femoral veins. Peri and less often endocarditis 
are complications. 

Anemia (pernicious). — Hemic murmurs con- 
stant. Visible arterial pulsations. Pulse full and 
suggests the water-hammer beat of aortic regurgi- 
tation. Capillary pulse often seen. Superficial 
veins prominent and may pulsate. 

Beight's Disease. — Anemia an early symptom. 
In the chronic forms, pulse tension increased and 
arterial wall thickened. Persistent high tension 
is one of the earliest and most important symptoms 
of interstitial nephritis (Osier). Hypertrophy of 
the left ventricle common. 

Chlorosis. — Palpitation of the heart. Increase 
in the area of cardiac dullness. Systolic murmur 
heard in second left interspace, accompanied some- 
times by a pulsation, and is produced at mitral 
orifice by relative insufficiency of the valves ac- 
companying dilated ventricles (Balfour). Over 
right jugular vein, a continuous murmur (bruit de 
diable or humming-top murmur). Pulsation in 
peripheral veins and a tendency to thrombosis, 



160 DISEASES OF THE HEART. 

usually in the femoral, occasionally in the longi- 
tudinal sinus. 

Chokea. — The theory is gaining ground that 
chorea is a rheumatic manifestation. Pericarditis 
and endocarditis frequent complications, the lat- 
ter occurring in about one-half of all cases (Osier). 
The murmurs may also he due to anemia. Osier 
examined 140 persons having suffered at least two 
years previously from chorea. In 51, heart nor- 
mal; in 72, signs of organic lesion; in 17, cardiac 
disturbances. 

Diabetes. — Plasma of blood is loaded with fat 
(lipemia) which form fat emboli in lung capillaries. 
Heart changes not characteristic and endocarditis 
is infrequent. Nutritional disturbances cause ar- 
terio sclerosis. 

Diphtheria. — Myocarditis and degeneration 
and endo and pericarditis may occur. Cyanosis 
and heart failure may be sudden. Myocarditis as 
a post-diphtheritic manifestation. Sudden death 
often caused by changes in vagus or its cardiac 
branches (neuritis) and may be a sequel of the 
mildest cases. 

Dyspepsia. — Flatulency may cause mechanic 
disturbance, viz., cardiac dyspnea or pseudo-anginal 
attacks. The pulse will be found weak and heart 
tones enfeebled. The left inter-scapular sign is 
present (Abrams). Heart neuroses frequently owe 



ADDENDUM. 161 

their genesis to the absorption of the products of 
indigestion. 

Emphysema.— In no other affection other than 
in congenital heart disease is cyanosis so marked 
and this, with comparative comfort of the patient. 
Dilatation and hypertrophy of right ventricle; 
later, hypertrophy is general. 

Exophthalmic Goitre. — Cardio-vascular dis- 
turbances occur early. Heart sound intense and 
may be heard as far as four feet from patient 
(Graves). Throbbing of carotids and abdominal 
aorta. Hypertrophy of heart and murmurs at 
base. 

Gout. — Arterio-sclerosis, common. Blood ten- 
sion persistently high leading to ventricular hyper- 
trophy, rupture of vessels (apoplexy) and aneurism. 

Grippe. — In the "influenza heart" cardiac weak- 
ness is very alarming and out of proportion to the 
height of the fever. Pulse feeble and intermittent 
and may persist after convalescence. 

Hysteria. — Increased heart rapidity on slight- 
est emotion. Pain in precardia may simulate an- 
gina. Stigmata or hemorrhages in the skin and 
flushes are vaso-motor phenomena. 

Icterus. — Slow pulse (30 or even 20) common. 
Ecchymoses in severe forms. 

Insanity. — Mental symptoms often associated 
with heart disease. Delirium, hallucinations and 
morbid impulses (suicide) frequently terminate the 



DISEASES OF THE HEART. 



close of the disease. Insanity may develop in 
aortic a*nd mitral disease in the stage of compensa- 
tion. 

Makasmus. — In the terminal stages of chronic 
diseases, thrombosis may occur in the sinuses 
(marantic thrombus). 

Neueasthenia. — Cardio-vascular symptoms 
often predominate. Palpitation, irregular and 
rapid action of the heart with cardiac pains. 
Slightest emotional disturbances excites heart and 
it is difficult to dissuade neurasthenics that there 
is no organic lesion. A throbbing aorta is a 
prominent symptom and is so pronounced as to 
suggest aneurism. Flushes of heat and hyperemia 
of skin common as vaso-motor phenomena. 

Phthisis. — False or cardio-pulmonary murmurs 
result from the contraction of a lung cavity caus- 
ing heart dislocation. The indurated lung inten- 
sifies the murmur. A systolic murmur at the apex 
may simulate mitral regurgitation. The murmur 
is usually caused by the impact of the heart upon 
partially consolidated lung tissue driving out the 
air. A murmur of this kind is superficial, most 
distinct during expiration and is inaudible when 
the patient lies down. In neurotic phthisical per- 
sons a false systolic murmur is heard at the apex 
when the heart action is excited. Chronic valvular 
cases, the mitral being most frequently involved 
(17 times in 20 cases). Congenital stenosis of pul- 



ADDENDUM. 163 

monary orifice is frequently associated with this 
disease. 

Pleueist. — With effusion either dislocates the 
apex or the whole heart. There is no twisting of 
the heart but a dislocation of the mediastinum 
which carries the heart with it. 

Pneumonia (ckoupotjs). — Average pulse rate, 
100-110. Heart failure is manifested by increased 
frequency (120 or more). Failure of right heart- 
chamber is indicated by dilatation of this ventricle, 
viz. : increased dullness to the right, epigastric pul- 
sation, systolic murmur, fetal heart sounds, espe- 
cially second pulmonic sound and venous stasis. 
It is the right ventricle which needs watching and 
any evidence to be gained is derived by frequent 
auscultation of the pulmonic tones and not by 
palpitation of radial pulse. 

Ehetjmatism. — Endocarditis is the most fre- 
quent complication, and the mitral segments are 
most frequently involved. Pericarditis is espe- 
cially frequent in children, and is attended by a 
peculiar delirium. Myocarditis is commonly as- 
sociated with endo-pericardial changes. 

Spinal Curvattjee. — Curvatures of the spine 
result in circulatory and respiratory disturbances. 
The heart of hunchbacks is usually increased in 
size and the right heart is generally dilated, re- 
sulting in disturbances in the pulmonic circula- 
tion. 



164 DISEASES OF THE HEART. 

Syphilis. — In the heart, gummata frequently 
involve the left ventricular wall and are usually 
encysted. A fibro-sclerotic myocarditis may cause 
sudden death. Syphilitic endocarditis is not in- 
frequent. Arterial syphilis may occur as an oblit- 
erating endarteritis or as a gummatous periarteritis 
implicating the coronary, cerebral and other 
arteries. 

The Uric Acid Diathesis has, of late, assumed 
an important position in clinical medicine. Pal- 
pitation of the heart is frequent, particularly after 
eating, and increased arterial tension is an early 
and prominent symptom. Its occurrence during 
an uric acid storm is pathognomonic and this fact 
I have learned to appreciate since using the tono- 
meter. Circulating uric acid produces universal 
arterio-spasm followed sooner or later by the well- 
known symptomatic complex — arterio-sclerosis, 
gout and contracted kidney. 

Clinical Memoranda of the Cardio-Vascular 

System. 

the pulse. 

1. The number of pulse and heart beats in a 
normal adult is 71-72 per minute. 

2. The pulse frequency in different ages in the 
male: 0-136; 5-88; 10-15, 78; 15-20, 69.5; 20-25, 
69.7; 25-30, 71; 30-50, 70. (Quetelet.) 



ADDENDUM. 165 

3. In the female, the pulse frequency is greater 
by from 1 to 4.5 beats a minute. 

4. Influence of position on pulse: In sitting 
posture, 5 beats more a minute than in recumbent 
position; standing, 9 beats more than while sitting 
and 14 more beats than in recumbent posture. 

5. Influence of activity: Slight activity in- 
creases beats 10-20 and running may increase the 
beats to 140 and this increase may last from \-l 
hour. 

6. Influence of food: After dinner the average 
increase is 10. 

7. Influence of the barometer: A barometric 
rise of 1| cm. increases the pulse frequency 1.3 per 
minute (Vierordt). 

8. In sleep the pulse is slower, especially in 
children. 

9. In fever the pulse rises synchronously with 
the temperature and averages an increase of 10 
beats for every degree above 98 deg. F. Expressed 
according to centigrade: P=80+8 (T— 37). 

10. Eelation in time of heart tone and radial 
pulse beats in seconds: Eadial pulse, 0.224 later 
than the first cardiac tone. The left is felt 0.01- 
0.03 of a second later than the right radial pulse. 

11. Eelation of respiration and pulse: 1:3^-4. 
It takes four times as long for the blood to go 
through the systemic as through the pulmonic cir- 
culation. 



lbb DISEASES OF THE HEART. 

THE HEAKT. 

1. The work of the right ventricle is one-eighth 
that of the left. 

2. The intensity of the heart tones is as follows, 
beginning with the loudest: 1, systolic mitral; 2, 
systolic tricuspid; 3, second pulmonic tone; 4, 
second aortic; 5, second mitral; 6, second tricuspid; 
7, systolic pulmonic; 8, systolic aortic tone. 

2. Eelative intensity of second sounds at base. 
Second pulmonic sound invariably accentuated in 
young children and frequent in youth. After the 
fortieth year it is rare to find a pulmonic second 
sound as loud as the corresponding second aortic 
sound. Between 20 and 30 there is no marked 
accentuation of either sound (Creighton). 

3. In embolism from endocarditis of left heart 
the organs are affected in the following propor- 
tions: Kidney, 57 times; spleen, 39 times; brain, 
15; skin, 14, and liver and intestines, 1 time 
(Sperling). 

4. Location of endocarditis in 300 cases: Mitral 
valve, 255 times; aortic valve, 129 times; tricuspid 
valves, 29 times; pulmonary valve, 3 times (Sper- 
ling). 

5. Endocarditis in the sexes: In 238 cases, 86 
males, 152 females (Willigk); in 230 cases, 118 
males, 112 females (Bamberger). 

6. Influence of pregnancy on heart affections 
from 84 observations by Porak: Condition sta- 



ADDENDUM. 167 

tionary in 25% of the cases, temporary aggrava- 
tion in 4.76%, persistent aggravation, 60.71%; 
improvement during child-bed, 26.19%; cardiac 
symptoms aggravated by labor, 13.09%. Death 
occurred before delivery, 5 times; during delivery, 
2 times; during child-bed, 25 times; after tem- 
porary improvement, 8 times. The foregoing- 
table refers to pronounced cardiac lesions. 

7. Insanity and heart disease: Among 68 cases 
of melancholia, 11 cases of heart disease (Esquirol); 
among 100 insane, 31 cases (Calmeil); 602 insane, 
75 cases (Vienna asylum). 

CHILDEElSr. 

1. The movements of the heart begin one- 
eighth of a minute after birth. 

2. The normal apex beat is usually in the fourth 
interspace just outside the mammary line. This 
position has been attributed to the greater relative 
narrowness of the infant's chest in the transverse 
diameter and the relatively larger heart. The 
than in the adult. Symington contends in opposi- 
tion to the current belief that the position of the 
heart and great vessels is the same as in the adult. 

3. Functional disorders: Up to the seventh year 
cardiac action during sleep is often of unequal 
strength and rhythm and prone to be irregular in 
the healthiest children during sleep and greatly 
influenced by breathing (Da Costa). Irregularity 



168 DISEASES OF THE HEART. 

during waking hours indicates cardiac disorder un- 
less there are evidences of meningeal disease 
(Smith). 

4. Bulging of precardia more frequent in car- 
diac diseases of children owing to flexibility of 
thorax. 

5. Aneurisms under the age of 20, if not trau- 
matic in origin are caused by embolism from a pre- 
existing endocarditis. The cerebral arteries are 
most frequently involved. 

6. The ductus arteriosus is not obliterated as a 
rule until two weeks after birth. Persistence of 
the same after the first month is pathologic. 

7. Most frequent congenital lesion is stenosis of 
the pulmonary artery. 

8. The most common evidence of a congenital 
heart lesion is cyanosis. It affects more male in- 
fants — 180 cases, two-thirds males (Aberle). 
Cyanosis does not always commence at birth and 
may be retarded in appearance for years. Club- 
bing of the fingers and toes and a pigeon-chest 
are two common abnormalities in cyanosis. Other 
general conditions are lack of heat and retarded 
development. 

9. Prognosis in cyanosis: Thirty-five per cent 
die before the end of the first year; more than two- 
thirds die before the age of eleven years, and only 
five lived more than 45 years (in 159 cases col- 
lected by Aberle). The most frequent modes of 



ADDENDUM. 



death are convulsions, dyspnea, hemorrhage, coma 
and phthisis. 

10. Most frequent lesions in cyanosis: Stenosis 
of pulmonary artery, transposed aorta and pul- 
monary artery, one auricle and one ventricle, right 
ventricle divided into two cavities by a super- 
numerary septum. In more than half the cases 
the lesion is located in the pulmonary artery. 



STETHOPHONOMETRY. 

Since reference was made, on page 55, to meth- 
ods of measuring the intensity of the heart tones, 
I have had constructed for me, after considerable 
experimentation, a simple stethophonometer, 
which can be readily attached to any stethoscope.* 




STETHOPHONOMETER. 



The stethophonometric attachment weighs about 
two ounces and is based on the principle of a disc 
valve with attachment on one side for the stetho- 
scope and on the other side for the bell. The 



* Made by the Shoenberg Electrical Co., E. Spreck- 
els Building, San Francisco. 



170 



DISEASES OF THE HEART. 



object of the valve is to offer resistance to the 
sound waves. There are three hard rubber discs, 
all of which are perforated. The center disc is 
easily movable by means of a handle so as to carry 
the opening away from the other two discs. On 
the face of one of the discs is a graduated scale, 
which enables one to measure the intensity of the 




STETHOPHONOMETRIC ATTACHMENT. 

cardiac tones. If the heart sounds are loud enough 
to overcome the resistance of the valves, further 
resistance may be offered by the insertion of a 
small rubber cork in the bore of the plug which 
fits into the stethoscope. It will rarely be found 
necessary to make use of the latter expedient. 



INDEX. 



Anemia (Pernicious) in 
relation to Heart Dis- 
ease, 159 
Anemia, Pulmonary, 46 
Anemic Murmurs, 45 
Aneurism, Locating Site 

of, 152 
Aneurism of Thoracic 
Aorta, 148 

etiology of, 148 

diagnosis of, 153 

pathology of, 148 

symptoms of, 149 

treatment of, 153 
Angina Pectoris, 137 

etiology of, 138 

pathology of, 138 

symptoms ,of, 138 

treatment of, 142 
Angina, Pseudo, 140 
Aorta, Aneurism of Thor- 
acic, 148 
Aortic Regurgitation, 34, 
114 

pulse in, 54 
Aortic Stenosis, 34, 116 

pulse in, 54 
Apex beat, 30 

location of, 31 

in hypertrophy, 50 

in dilatation, 51 
Aphasia, Temporary, 21 



Arrythmia, 66, 136 

etiology of, 137 

significance of, 137 
Arterial Sclerosis, 144 
Arterial wall, condition 

of, 51 
Arteries 

condition of wall of, 51 

atheroma of, 51 
Arteries, Affections of, 
144 

atheroma, 144 

aneurism of thoracic 
aorta, 148 
Asthma, Bronchial, 19 

from cardiac asthma, 19 
Asthma, Cardiac, 18 

from bronchial asthma, 
19 
Asthma Dyspepticum, 16 
Atheroma, 51, 144 

etiology of, 144 

pathology of, 144 

symptoms of, 145 

treatment of, 148 
Bamburger Sign, 99 
Baths, Saline, 76 
Blood vessels, 13 
Brachycardia, 54, 113 

symptoms of, 135 

treatment of, 135 



II. 



INDEX. 



Breast Pang, 137 
Bright's Disease 

in relation to Heart 
Disease, 159 
Cardiac Cachexia, 12 
Cardiodynia, 137 
Cardio-respiratory mur- 
murs, 45 
Children, Heart in, 167 
Chlorosis 
in relation to Heart 
Disease, 159 
Chorea 
in relation to Heart 
Disease, 160 
Compensation, 11 
Treatment during stage 
of, 68 
Compensation, Failure of, 
11 
Dilated Heart as cause 

of, 50 
Treatment during stage 
of, 70 
Corrigan's Pulse, 54 
Cough, Treatment of, 89 
Cyanosis, 12 

Degeneration, Fatty, 126 
Diabetes 

in relation to Heart 
Disease, 160 
Digestive Apparatus, 19 
Dilatation of Heart, 50 
apex beat in, 51 
symptoms of, 50 



Diphtheria in relation to 

Heart Disease, 160 
Dropsy, Treatment of, 85 
Dropsy, Cardiac, cause of, 

12 
Dropsy of Pericardium, 

107 
Dyspepsia in relation to 

Heart Disease, 160 
Dyspnea, 13 

Treatment of, 85 
Dyspnea, Gastrectatic, 14 
course of, 14 
with angina pectoris, 15 
Edema of the Lungs, 14 
Emboli, 13 
Emphysema in relation to 

Heart Disease, 161 
Endocarditis, 22, 109 
chorea as cause of, 22 
forms of, 24 
chronic, 24, no 
Gonorrheal, 109 
Malignant, 24, no 
Simple, 24, no 
Ulcerative, no 
Valvular, 23 
results of, 25 
Exophthalmic Goitre in 
relation to Heart Dis- 
ease, 161 
Exercise in treatment of 

heart disease, 83 
Fatty Degeneration of 
Heart, 126 



INDEX. 



III. 



Fatty Heart, 126 
Fatty Overgrowth, 127 
Fibrosis, Arterio-Capil- 

lary, 144 
Gastrectatic Dyspnea, 14 

cause of, 14 

with angina pectoris, 15 
Gastric Complications 

Treatment of 90 
Glottis, Edema of, 14 
Gout in relation to Heart 

Disease, 161 
Grippe in relation to Heart 

Disease, 161 
Heart, 166 

clinical memoranda of, 
166 

Dilatation, 50 

Endocarditis, 23, 109 

Hypertrophy of, 49 

in children, 167 

inhibition of, 59 

Neuroses of, 128 

Tones of, 55 
Heart, Diseases of, 21 

Aortic Regurgitation, 
34, 114 

Aortic Stenosis, 34, 116 

Congenital, 124 

Diagnosis of, 30 
X-Ray in, 63 

Dilatation of, 25 

Endocarditis, 22, 109 

Etiology of, 23 

Fatty Degeneration, 126 

Fatty Heart, 126 



Fatty Overgrowth, 127 

Heart Strain as cause 
of, 25 

Hypertrophy of, 25, 49 

in febrile affections, 21 

in pregnancy, 22 

in relation to other dis- 
eases, 21, 158 

Mitral Regurgitation, 
36, 117 

Mitral Stenosis, 12, 36, 
118 

Myocarditis, 125 

Prevention in, 65 

Prognosis of, 27 

Pulmonary Regurgita- 
tion, 121 

Pulmonary Stenosis, 
121 

Pulse in, 51 

Treatment of, 65 

Tricuspid Regurgita- 
tion, 120 

Tricuspid Stenosis, 121 
Heart Diseases, in rela- 
tion to, 158 

Abdominal Typhus, 158 

Anemia (Pernicious), 
159 

Bright's Disease, 159 

Chlorosis, 159 

Chorea, 160 

Diabetes, 160 

Diphtheria, 160 

Dyspepsia, 160 

Emphysema, 161 



IV. 



INDEX. 



Exophthalmic Goitre, 
161 

Gout, 161 

Grippe, 161 

Hysteria, 161 

Icterus, 161 

Insanity, 161 

Marasmus, 162 

Neurasthenia, 162 

Phthisis, 162 

Pleurisy, 163 

Pneumonia (Croup- 
ous), 163 

Rheumatism, 163 

Spinal Curvature, 163 

Syphilis, 164 

Uric-Acid Diathesis, 
164 
Heart, Irregular (Arryth- 

mia), 136 
Heart, Rapid (Tachycar- 
dia), 132 
Heart Reflex, 155 
Heart Stout (Bradycar- 
dia), 134 
Heart Strain, 25 
Heart Tones 

Aortic, 58 

Intensity of, 55 

Mitral, 58 

Pulmonic, 58 

Tricuspid, 58 
Heart Tonics, 71 

Table of, 77 
Hemic Murmurs, 46 



Hemopericardium, 107 

causes of, 107 

treatment of, 108 
Hemoptysis, 14 

Treatment of, 89 
Hemorrhages, Cutaneous, 

12 
Hydropericardium, 107 

etiology of, 107 

pathology of, 107 

symptoms of, 107 

treatment of, 107 
Hypertrophy of Heart, 49 

apex beat in, 50 

diagnosis of, 49 

symptoms of, 49 
Hysteria 

in relation to Heart 
Disease, 161 
Icterus 

in relation to Heart 
Disease, 16 
Incompetency, Aortic, 114 

characteristics of mur- 
murs of, 114 

course of, 115 

physical signs of, 114 

symptoms of, 114 

treatment of, 115 
Incompetency, Mitral, 117 

diagnosis of, 117 

symptoms of, 117 
Incompetency, Pulmonary, 
121 



INDEX. 



Incompetency, Tricuspid, 
120 
diagnosis of, 120 
symptoms of, 120 
Inhibition of Heart 

as aid to Diagnosis, 59 
Insanity in relation to 

Heart Disease, 161 
Jaundice, 12 
Kidneys, 20 
Liver and Spleen, 20 
Lungs, 13 
Edema of, 14 
Hemorrhage of, 14 
Lung Gymnastics, 81 
Marasmus in relation to 

Heart Disease, 162 
Mediastino-Pericarditis, 
106 
etiology of, 106 
symptoms of, 106 
Mitral Regurgitation, 36, 
117 
diagnosis of, 117 
pulse in, 54 
symptoms of, 117 
Mitral Stenosis, 12, 36, 118 
pulse in, 54 
symptoms of, 118 
Murmurs, 25, 31 
accidental, 36 
analectic review of, 38 
anemic, 45 

cardio-respiratory, 45 
character of, 33 



diastolic, 32, 33 
hemic, 46 
inorganic, 

tabular review of, 40 
nature of, 32 
obstructive, 25 

character of, 33 
of apprehension, 36 
of gastric origin, 37 
organic, 31 

tabular review of, 40 
origin of, 31 
Pericardial, 41 
Pleuro-pericardial, 45 
presystolic, 32, 33 
regurgitant, 25 

character of, 33 
seat of, 31 
significance of, 30 
subclavian, 47 
systolic, 32, 33 
tabular review of or- 
ganic and inorganic, 
40 
time of, 32 
transmission of, 32 
valvular cardiac, 42 

tabular review of, 42 
venous subclavian, 48 
Myocarditis, 125 
Nervous Symptoms, 

Treatment of, 89 
Nervous System, 21 
Neurasthenia in relation 
to Heart Disease, 162 



VI. 



INDEX. 



Neuroses of Heart, 128 


Pyo-pneumopericar- 


Etiology of, 128 


dium, 108 


Obstruction, Aortic, 34 


Phthisis in relation to 


pulse in, 54 


Heart Disease, 162 


Obstruction, Mitral, 36 


Pleurisy 


pulse in, 54 


in relation to Heart 


Oertel, Method of in 


Disease, 163 


treatment of Heart Dis- 


Pleuro-pericardial mur- 


ease, 83 


murs, 45 


Palpitation, 130 


Pneumonia (croupous) 


Diagnosis of, 130 


in relation to Heart 


Treatment of, 84, 130 


Disease, 163 


Paroxysmal Tachycardia, 


Pneumopericardium, 108 


132 


cause of, 108 


Diagnosis of, 132 


symptoms of, 108 


Treatment of, 132 


treatment of, 108 


Pectoris, Angina, 137 


Precordial Pain, 13 


Pericardial Murmurs, 41 


Prevention in Diseases of 


Pleuro-, 45 


Heart, 65 


Pericarditis 


Pseudo-Angina, 140 


Acute Plastic, 93 


Pulmonary Anemia, 46 


Adherent, 106 


Pulse, 12 


Chronic Adhesive, 106 


character of, 12 


Fibrinous, 93 


Corrigan's, 54 


Mediastino, 106 


frequency, 54 


Purulent, 104 


frequency in different 


with effusion, 103 


ages, 164 


Pericardium, Affections 


in aortic regurgitation, 

54 
in aortic stenosis, 54 


of, 93 


Dropsy of, 107 


in exudative pericardi- 


Hemopericardium, 107 


tis, 55 


Hydropericardium, 107 


in fever, 165 


Pericarditis, 93 to 106 


in mitral insufficiency, 


Pneumopericardium, 


54 . 


108 


in mitral stenosis, 54 



INDEX. 



VII 



in myocarditis, 55 

in sexes, 165 

in sleep, 165 

Influences on, 165 

intermittent, 13 

irregular, 53 

rate, 164 

rhythm, 53 

tension of, 53 

to respiration, 165 

volume of, 53 
Pyo-pneumopericardium, 

108 
Reflex, Heart, 155 
Regurgitation Aortic, 34, 
114 

Mitral, 117 

Pulmonary, 121 

Tricuspid, 120 
Renal Complications, 
Treatment of,. 90 
Resistance Movements, 

176 
Rheumatism in relation to 

Heart Disease, 163 
Rotch Sign, 97 
Schott Treatment, 76 
Sphygmograph, 54 
Spinal Curvature in rela- 
tion to Heart Disease, 
163 
Spleen, Liver and, 20 
Sternocardia, 137 
Stenosis, Aortic, 116 

Mitral, 118 

Pulmonary, 121 



Tricuspid, 121 
Stomach, Acute Dilatation 

of, 14 
Subclavian Murmurs, 47 

venous-, 48 
Syphilis in relation to 

Heart Disease, 164 
Tachycardia Paroxysmal, 
132 
Diagnosis of, 132 
Treatment of, 133 
Thromboses, 13 
Tonics, Cardiac, 71 

Table of, 77 
Tonometer, Gaertner, 147 
Treatment of Diseases of 
Heart, 65 
by Baths, 78 
by Home Exercise, 83 
by Lung Gymnastics, 81 
by Method of Oertel, 83 
by Resistance Move- 
ments, 79 
by Schott Methods, 76 
by Tonics, 71 
during Compensation, 

68 
during failure of com- 
pensation, 70 
Treatment of Individual 
Symptoms in Diseases 
of Heart, 84 
Tricuspid Regurgitation, 
120 
Diagnosis of, 120 
Treatment of, 120 



VIII. 



INDEX. 



Tricuspid Stenosis, 121 


Mitral Regurgitation, 


Tremors, purring, 34 


117 


Typhus, Abdominal, in re- 


Mitral Stenosis, 118 


lation to Heart Dis- 


Pulmonary Regurgita- 


ease, 158 


tion, 121 


Uric-Acid Diathesis 


Pulmonary Stenosis, 


in relation to Heart 


121 


Disease, 164 


Tricuspid Regurgita- 


Valvular Disease, Chronic, 


tion, 120 


114 


Tricuspid. Stenosis, 121 


Aortic Regurgitation, 


Valvular Lesions, effect 


114 


of secondary, 34 


Aortic Stenosis, 116 


Frequency of, 27 


Combined, 122 


X-Rays in Cardiac Diag- 


Diagnosis, 123 


nosis, 63 






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